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R  A776  P99  1 907    A  manual  ol  personal 


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Hygiene 


Pyle 


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COLLEGE  OF  PHYSICIANS 
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A  MANUAL 

OF 

Personal  Hygiene 

Proper  Living  upon  a  Physiologic  Basis 
BY  AMERICAN  AUTHORS 

EDITED  BY 

WALTER  L.  PYLE,  A.M.,  M.D. 

Member  of  the  American  Ophthalmological    Society  ;     Fellow   of  the 

American  Academy   of  Medicine;    Fellow  of  the   College  of 

Physicians  of  Philadelphia  ;  Assistant  Surgeon  to  the 

Wills   Eye  Hospital,  Philadelphia,  etc. 

CONTRIBUTORS 

D.  H.   BERGEY,   M.D.  "WALTER  L.  PYLE,  M.D. 

J.  "W.   COURTNEY,  M.D.  B.  ALEXANDER  RANDALL,  M.D. 

GEORGE  HOWARD  FOX,  M.D.    G.  N.  STEWART,  M.D.  (Edin.) 

E.  FLETCHER  INGALS,  M.D,        CHARLES  G.  STOCKTON,  M.D. 

THIRD  EDITION,  REVISED  AND  ENLARGED 


PHILADELPHIA  AND    LONDON 

W.  B.  SAUNDERS  COMPANY 

1907 


Set  up,  electrotyped,    printed,  and   copyrighted  May,  1900.      Reprinted   and 

recopyrighted  April,  igoi.     Revised,  reprinted,  and  recopyrighted 

August,    1904.     Reprinted   August,    1905.      Revised, 

reprinted,  and  recopyrighted  January,  1907 


Copyright,  1907,  by  W.  B.  Saunders  Company 


ELECTROTYPED     BY  PRESS    OF 

WESTCOTT  &  THOMSON,   PHILA.  W.   B.   SAUNDERS  COMPANY 


PREFACE, 


The  object  of  tlii.s  nianual  is  to  .set  forth  plainly  the  best 
means  of  developing  and  maintaining  physical  and  mental 
vigor.  Throughout  the  book  there  is  concise  but  adequate 
discussion  of  the  anatomy  and  physiology  of  the  parts  under 
consideration,  upon  which  is  based  the  subjoined  advice.  In 
other  words,  there  is  an  exposition  of  proper  living  upon  a 
physiologic  basis.  Purely  technical  phraseology  has  been 
avoided,  as  far  as  compatible  with  the  scientific  value  of  the 
text,  and  numerous  explanatory  diagrams  and  illustrations 
have  been  introduced.  Although  each  special  chapter  is  com- 
plete in  itself,  there  has  been  purposive  repetition  of  remarks 
upon  subjects  of  such  general  interest  as  eating,  drinking, 
breathing,  bathing,  sleep,  exercise,  etc.,  in  order  that  the}^ 
may  be  discussed  more  thoroughly  from  several  standpoints. 

WALTER  L.  PYLE. 


PREFACE  TO  THE  THIRD  EDITION. 


In  response  to  a  growing  demand,  the  work  has  been 
thoroughl}''  revised  and  numerous  additions  have  been  made, 
including  an  illustrated  System  of  Home-G5'mnastics,  a  chap- 
ter on  Domestic  Hj'giene,  and  an  Appendix,  containing  the 
simpler  methods  of  Hydrotherapy,  Thermotherap^^  and  Me- 
chanotherap3^  and  a  section  on  First  Aid  in  Medical  and 
Surgical  Accidents  and  Emergencies.  A  concise  Glossars*  of 
the  purel}-  medical  words  unavoidably  used  in  the  text  has 
been  especially  prepared  for  the  convenience  of  non-medical 
readers. 

WALTER  L.  PYLE. 
1806  Chestnut  St.,  Philadelphia. 


INTRODUCTION.' 


Strange  as  it  may  seem,  the  one  subject  which 
every  fair-minded  person  admits  should  be  taught 
thoroughly — namely,  how  to  keep  healthy — has  been 
largely  neglected.  .With  all  the  recent  agitation  for 
educational  reform,  there  remains,  in  a  measure, 
the  same  indifference  to  the  proper  teaching  of  the 
care  of  the  body,  regarding  which  Herbert  Spencer 
lectured  the  pedagogic  world  over  forty  years  ago. 

Mr.  Spencer  proved  that  knowledge  may  have  in- 
trinsic value,  and  that  the  value  of  some  knowledge 
must  be  greater  than  that  of  others.  In  our  brief 
lives  it  is  most  necessary  to  distinguish  and  give 
precedence  to  the  useful,  real,  and  effective  over  the 
non-useful,  conventional,  and  ornamental  ;  or,  to  use 
a  Baconian  phrase,  "we  must  determine  the  relative 
value  of  knowledges."  All  knowledge  passes  into 
action,  and  that  knowledge  that  leads  men  to  better 
physical  lives  is  a  communal  as  well  as  an  individual 
gain.  Mr.  Spencer  says  that,  in  the  order  of  their 
importance,  the  leading  kinds  of  activity  which  con- 
stitute human  life  are  : 

I.  Those  activities  which  directly  minister  to  self- 
preservation. 

'  A  considerable  portion  of  this  introductoiy  chapter  is  from  an  ad- 
dress by  the  editor  in  oj^ening  the  Sj'mposium  of  the  American  Academy 
of  Medicine,  on  the  "  Teaching  of  Hygiene  in  the  Public  Schools,"  in 
Washington,  D.  C,  May  ii,  1903. 


VI  INTR  OD  UCTl  ON. 

2.  Those  activities  wliicli,  by  securing  the  neces- 
saries of  life,  indirectly  minister  to  self-preservation. 

3.  Those  activities  which  have  for  their  end  the 
rearing  and  disciplining  of  offspring. 

4.  Those  activities  which  are  involved  in  the  main- 
tenance of  proper  social  and  political  relations. 

5.  Those  miscellaneous  activities  which  make  up 
the  leisure  part  of  life,  devoted  to  the  gratification  of 
the  taste  and  feelings. 

In  other  words,  a  rational  order  of  subordination 
is  :  Education  which  prepares  for  a  direct  self-preser- 
vation ;  that  which  prepares  for  an  indirect  self-pres- 
ervation ;  that  which  prepares  for  parenthood  ;  that 
which  prepares  for  citizenship  ;  and  that  which  pre- 
pares for  miscellaneous  refinements. 

It  is  stated  with  great  emphasis  that  without  doubt 
the  actions  and  precautions  which  from  moment  to 
moment  secure  self-preservation  are  of  primary  im- 
portance ;  and  that,  "as  vigorous  health  and  its 
accompanying  high  spirits  are  larger  elements  of 
happiness  than  any  other  things  whatsoever,  the 
teaching  how  to  maintain  them  is  a  teaching  that 
should  yield  in  moment  to  no  other  whatever." 

Fortunately,  knowledge  subserving  direct  self-pres- 
ervation is  largely  provided  for  by  nature.  The  com- 
mon animal  instincts  give  warning  against  gross  dan- 
gers. The  inquisitive,  timid,  restless  infant  is  chiefly 
concerned  in  hourly  acquisition  of  the  primitive  facul- 
ties of  coordination,  estimation  of  distance,  size,  con- 
sistence, and  weight,  the  avoidance  of  things  likely 
to  cause  pain,  the  assimilation  of  food,  etc.  Through- 
out childhood  and  youth  there  is  a  further  elaboration 
of  these  primal  requisites.      But  more  than   this  is 


JNl'NODUVJ'ION.  Vll 

necessary,  for  besides  the  ineclianical  dangers,  there 
are  the  evils  following  breaches  of  physiologic  laws. 
Unfortnnately,  so  profonnd  is  the  innate  ignorance  of 
these  laws  of  life  that  it  is  often  not  even  known  that 
our  sensations  are  our  natural  and  most  trnstworlhy 
guides.  The  less  evident  but  no  less  real  dangers 
arising  from  the  complexities  of  modern  social  life 
and  the  attendant  evil  habits  are  continually  present, 
despite  all  innate  instincts  of  waruing.  The  per- 
nicious influence  of  improper  food  and  bad  air,  the 
abuse  of  stimulants  "and  narcotics,  the  modern  dissi- 
pations and  vices,  etc.,  can  be  modified  only  by  proper 
and  timely  education. 

It  has  been  said  that  "health  is  man's  birthright  ; 
that  it  is  as  natural  to  be  well  as  to  be  born,"  and 
that  from  ignorance  and  transgressions  of  physiologic 
and  hygienic  laws  arise  most  disease  and  tendency  to 
disease.  Yet  to-day,  so  tardy  has  been  the  recog- 
nition of  the  importance  of  instruction  in  the  funda- 
mental principles  of  applied  physiology  as  a  means 
to  complete  living,  that  a  thoroughly  well  person 
after  middle  life  is  the  exception  in  every  com- 
munity. On  every  side  we  find  chronic  complaint, 
physical  weakness,  weariness,  and  overwhelming 
gloom,  which  might  have  been  prevented  by  proper 
timely  instruction. 

A  striking  example  of  the  sacrifice  of  health  from 
avoidable  and  preventable  suffering  is  the  great  num- 
ber of  physical  and  moral  wrecks,  the  victims  of  the 
very  prevalent  habit  of  worry.  So  close  are  the  rela- 
tions of  the  mind  an  i  the  body  that  one  of  the  most 
prolific  sources  of  suffering  is  continuous  worry,  and  one 
of  the  surest  wavs  to  restore  health  that  is  threatened 


VUl       ,  INl'KODUCTION. 

is  to  keep  the  mind  cheerful  and  hopeful.  Excessive 
ambition,  misdirected  energy,  longing  for  the  unattain- 
able, regret  for  the  unalterable,  anticipation  of  future 
happenings,  lack  of  a  sense  of  perspective,  fretting 
over  non-essentials,  indecision,  reopening  of  trouble- 
some questions  already  settled,  avarice,  selfishness, 
excessive  emotions,  uncontrolled  passions,  and  the 
actual  cultivation  of  the  melancholic  state,  are  some 
of  the  important  causes  of  mental  anguish  and  sub- 
sequent physical  suffering  that  are  not  commonly 
associated  with  the  baneful  breaches  of  hygienic 
laws  to  be  demonstrated  by  teachers  of  practical 
physiology.  With  those  who  are  physically  or  men- 
tally defective  we  have  the  patience  to  reason  and  to 
make  allowance  for,  but  little  sympathy  or  guidance 
is  offered  to  the  practically  normal  person  who  is 
gradually  becoming  the  slave  of  a  cultivated  habit  of 
worry,  letting  the  minor  trials  and  troubles  of  a  day 
shut  out  much  of  the  sunshine  and  happiness  of  life. 
The  spiritual  sin  of  worry  and  its  utter  futility  should 
be  made  plain,  but  its  association  with  chronic  ill- 
health  needs  more  discussion  in  both  schools  and 
churches.  Observance  of  such  teaching  would  do 
much  to  lessen  the  great  American  army  of  neu- 
rasthenics. 

Besides  the  individual  suffering  from  preventable 
illness,  time  and  money  are  ruthlessly  wasted,  com- 
mercial and  artistic  instincts  are  curtailed,  good 
parenthood  and  citizenship  are  rendered  impossible, 
appreciation  of  amusement  is  dulled,  and,  besides 
being  immensely  deteriorated,  life  is  markedly  short- 
ened. "Is  it  not  clear,"  asks  Mr.  Spencer,  "that 
the  physical  sins — partly  our  forefathers'  and  partly 


JN'l'R  on  UCTION.  IX 

onr  own — which  produce  this  ill-licaltli  deduct  more 
from  complete  Hvin<r  than  aiiythin.t^  else,  and  to  a 
greater  extent  make  life  a  failnre  and  a  bnrden  in- 
stead of  a  benefaction  and  a  pleasure?" 

Most  cases  of  illness  are  preventable,  and  Mr. 
Huxley  says  we  should  look  upon  them  as  criminal. 
Illness  following  disobedience  of  physiologic  laws 
should  be  regarded  as  the  punitive  result  of  repre- 
hensible conduct  and  not  as  a  simple  grievance. 
There  is  such  a  thing  as  physical  morality  and  the 
preservation  of  health  should  be  considered  a  sacred 
duty.  Persons  who  treat  their  bodies  as  they  please 
and  transgress  rules  of  personal  hygiene  of  which 
they  should  have  a  definite  understanding  are  physi- 
cal sinners,  and  they  are  not  only  committing  a  crime 
against  themselves,  but  often  against  their  dependents 
and  future  generations. 

Public  hygiene  may  be  enforced,  but  personal  and 
domestic  hygiene  must  be  taught.  No  law  can 
compel  citizens  in  times  of  epidemics  of  typhoid 
fever  or  cholera  to  boil  their  drinking-water  and 
cleanse  food  that  is  to  be  eaten  without  cooking,  but 
persistent  warnings  from  the  health-authorities,  pub- 
lic lectures,  and  literature  from  physicians,  and  news- 
paper and  periodical  discussion  will  be  of  the  greatest 
service  in  combating  the  spread  of  disease.  General 
sanitarj^  improvement  is  dependent  upon  the  intelli- 
gence of  the  community,  as  well  as  upon  efficient 
health-officials,  and  one  of  the  important  duties  of 
the  latter  should  be  to  strengthen  public  confidence 
and  disseminate  more  widely  knowledge  concerning 
public,  domestic,  and  personal  hygiene. 

It  is  not  merely  the  teaching  of  the  rules  of  hygiene 


X  INTRODUCTION. 

that  is  needed,  nor  the  ordinary  course  in  school- 
physiology.  Personal  hygiene  is  applied  physiology, 
and  a  proper  understanding  of  certain  elemental -truths 
must  be  acquired  before  they  can  be  applied.  Knowl- 
edge of  the  normal  functions  of  the  body  and  the 
simple  methods  of  keeping  them  in  healthy  action 
is  the  one  thing  that  no  educated  person  should  be 
excused  from  possessing  ;  yet  most  of  our  children 
reach  maturity  without  sufficient  parental  or  scho- 
lastic instruction  in  many  essential  matters  of  health. 
Men  and  women  who  would  be  greatly  chagrined  to 
be  corrected  in  the  pronunciation  of  a  popular  foreign 
proper  name,  or  who  would  resent  as  an  insult  any 
imputation  as  to  their  lack  of  general  culture  or 
learning,  show  not  the  slightest  embarrassment  at 
their  ignorance  of  the  common  physiologic  functions 
of  digestion,  circulation,  respiration,  etc.  Persons 
of  intelligence  continually  furnish  thoughtless  rec- 
ommendations of  purely  "quack"  remedies  and  un- 
scientific instruments  and  apparatus  ;  and  advertise- 
ments of  these  articles  may  be  seen  in  the  best  gen- 
eral and  religious  periodicals. 

Concerning  the  popular  desire  of  the  British  Uni- 
versity patrons  for  the  classic  instruction,  Mr.  Spencer 
says  :  "  While  anxious  that  their  sons  should  be  well 
up  in  the  superstitions  of  two  thousand  years  ago, 
they  care  not  that  they  should  be  taught  anything 
about  the  structures  and  functions  of  their  own 
bodies — nay,  would  even  disapprove  such  instruc- 
tion. vSo  overwhelming  is  the  influence  of  estab- 
lished routine  !  So  terribly  in  our  education  does 
the  ornamental  override  the  useful  !"  Is  this  not 
a  fairly  applicable  arraignment  of  not  a  few  Ameri- 


JN'J'ROJWCTION.  XI 

can  parents — especially  as  to  the  dan^liter's  educa- 
tion? yet  it  is  to  the  mothers  of  to-day  that  the  regi- 
men of  the  nursery,  the  rearing-  of  children,  the 
preparation  of  food,  and  the  problems  of  domestic 
hygiene  are  largely  left. 

The  literature  for  the  layman  pertaining  to  personal 
hygiene  is  in  great  measure  unsatisfactory  and  irre- 
sponsible. Many  of  the  so-called  "health  books" 
are  of  very  questionable  authorship,  often  the  com- 
pilation of  a  layman,  perhaps  an  amateur  pathologist, 
an  inaccurate  physiologist,  a  moralist  of  vague  opin- 
ions, with,  unfortunately,  a  tendency  to  cater  to  the 
prurient.  Such  books  make  hypochondriacs  of  their 
readers,  and  if  they  include  advice  as  to  self-treatment, 
they  may  do  great  harm.  It  is  the  duty  of  the  pro- 
fessional author  to  stem  and  correct  any  morbid  atti- 
tude of  his  readers,  and  not  to  add  to  it  under  the 
pretext  of  necessary  explanation.  In  this  connection 
may  be  aptly  quoted  the  following  abstract  from  a 
recent  editorial  in  the  British  Medical  Journal :  "  If 
we  may  speak  for  parents  in  the  medical  profession, 
it  is  impossible  to  suppose  that  wise  fathers  and 
mothers  could  desire  to  suggest  to  their  sons  or 
daughters  either  certain  problems  raised  or  in  many 
cases  the  explanations  proffered.  There  is  a  multitude 
of  the  best  parents  who  think  that  their  way  is  not 
made  easier  by  the  so-called  moral  reformer,  but 
rather  the  reverse.  And  there  are  man}-  of  the  most 
wholesome-minded  boys  and  sweetest  girls  who  hate 
him  with  a  perfect  hatred.  The  rest  would  probably 
do  very  well  without  him." 

Many  of  the  so-called  "school-physiologies''  fall 
short  of  their  purpose  by  an  inadequate  conception  of 


Xll  INTRODUCTION. 

the  proper  methods  of  teaching  hygiene.  Not  nncom- 
monly  they  aie  filled  with  a  mass  of  intricate  and 
useless  anatomic  data,  and  abstruse  and  unsettled 
questions  in  j)hysiology  that  can  be  of  no  possible  aid 
to  either  teacher  or  pupil  in  the  practical  application 
of  the  principles  of  personal  hygiene.  It  is  of  great 
importance  to  begin  this  teaching  early,  before  habits 
of  carelessness  and  indifference  to  things  hygienic  are 
formed.  For  this  reason  the  home  and  the  primary 
schools  are  by  all  means  the  places  where  the  "gospel 
of  health"  should  first  be  promulgated.  If  parents 
and  teachers  are  given  the  proper  literature  from 
which  to  prepare  their  instruction,  they  can  readily 
impart  to  very  young  children  many  of  the  most 
important  lessons  in  practical  hygiene — as,  for  in- 
stance, the  principles  of  contagion  and  the  advan- 
tages of  cleanliness.  Children  more  advanced  may 
be  taught  by  illustrated  talks,  without  the  necessity  of 
text-book  study,  the  salient  principles  of  hygiene  of 
digestion,  proper  breathing,  the  care  of  the  eyes,  ears, 
skin,  etc.,  and  these  lessons  may  be  so  firmly  im- 
pressed while  the  mind  and  character  are  in  the 
developmental  stage  that  they  are  never   forgotten. 

Some  idea  of  the  far-reaching  effects  of  a  general 
adoption  of  these  simple  methods  of  instruction  in 
the  proper  care  of  the  body  may  be  formed  from  the 
following  editorial  comment  of  a  prominent  maga- 
zine^ on  the  praiseworthy  effort  of  the  Teacher's 
College  of  the  Columbia  University  in  New  York 
city  to  train  teachers  "  to  teach  health  ": 

"It  may  not  be  extravagant  to  say  that  this  same 
movement  is  of  larger  possible  benefit  than  anything 

^  World's  Wo?-k,  February,  1903. 


INTRODUCTIOM.  xiil 

which  has  hitherto  been  done  in  the  name  of  ednca- 
tion,  for  if  it  should  ever  come  to  pass  that  every 
pupil  in  the  public  schools  should  be  brought  naturally 
to  a  proper  understanding-  of  health  and  its  relations 
to  every  other  part  of  life  and  conduct,  such  a  chance 
for  the  advancement  of  the  human  race  would  be 
given  as  no  considerable  section  of  society  has  yet 
ever  had.  If  all  easily  preventable  physical  troubles 
were  prevented,  such  an  addition  would  be  made  to 
the  energy  and  the  good  sense  of  the  people  as  defies 
description.  A  merely  incidental  item  of  such  social 
progress  would  be  the  incalculable  saving  of  the  money 
spent  on  quackery,  and  of  the  waste  of  energy  that 
quackery  causes." 

In  view  of  the  great  importance  of  personal  and 
domestic  hygiene  and  the  deficient  popular  instruction 
in  the  prevention  of  disease,  a  glorious  opportunity 
awaits  the  philanthropist  who  will  devote  his  energy 
and  fortune  to  this  teaching  by  public  lectures  and 
the  dissemination  of  authoritative  literature  through 
every  State  in  the  Union. 

In  literature  and  lectures  on  hygienic  subjects  too 
often  the  science  is  made  too  popular,  or  the  popular 
exposition  too  scientific.  There  has  also  been  too 
frequently  a  tendency  to  present  as  much  of  the 
"gospel  of  health  "  as  may  be  put  in  popular  form, 
or  that,  for  ulterior  motives,  the  layman  may  be  in- 
duced to  accept.  Such  attitude  can  only  weaken  the 
cause  of  preventive  medicine  among  intelligent  per- 
sons. It  is  not  desirable  to  produce  athletes,  physical- 
culture  fanatics,  or  practitioners  of  new-fangled  and 
erratic  "systems"  and  "pathies."  What  is  needed 
is  simple  instruction  by  capable  teachers  in  the  proper 


XIV  INTRODUCTION. 

care  and  use  of  the  body,  authoritatively  based  upon 
the  best  available  modern  anatomic,  physiologic,  and 
hygienic  data.  We  should  not  have  "every  man  his 
ovs^n  physician,"  as  seems  often  the  object  in  lectures, 
periodicals,  and  books  relating  to  health  ;  rather  give 
every  man  fundamental  knowledge  that  will  enable 
him  to  understand,  and,  if  necessary,  formulate,  the 
requisite  rules  of  health,  and  to  distinguish  scientific 
medicine  from  quackery.  Stripped  of  its  superfluous 
technicalities,  this  knowledge  may  be  imparted  to  any 
one  of  average  intelligence  and  education,  and  it  is 
desirable  that  more  literature  and  personal  explana- 
tion in  this  direction  should  come  from  the  American 
medical  profession.  The  subject  is  much  too  impor- 
tant to  be  left  entirely  in  the  hands  of  lay  teachers 
and  writers. 


TABLE  OF  CONTENTS. 


HYGIENE  OF  THE   DIGESTIVE   APPARATUS. 

By  Chas.  G.  Stockton,  M.  D.,  ok  Buffalo, 

Professor  of  Medicine  in  the  Medical   Department  of  the  University  of  BuflTalo. 

Physiology  of  Digestion,  9 — Mastication  and  insalivation,  9 — The 
stomacii,  10 — Tlie  small  intestine,  13 — Accessory  digestive  organs,  15 — 
The  large  intestine,  16— Hygiene  of  the  Teeth,  17 — Deformities,  17 — 
Causes  of  decay,  20 — Preservation,  23 — Tooth-brushes,  23 — Tooth-powder, 

24 — Importance  of  teeth  in  digestion,  25— Hygiene  of  the  Gastro- 
intestinal tract,  26 — The  appetite,  26 — The  effect  of  mind  on  nutrition, 
27 — The  effect  of  eye-strain  on  nutrition,  28 — Regulation  of  meals,  30 — 
Regulation  of  diet,  32— Proper  cooking,  35 — Fruits,  36 — Coffee,  tea,  and 
cocoa,  36 — Sugar,  37 — Fats  and  oils,  37 — Drinking  water,  39 — Alcoholic 
beverages,  40 — Otiier  stimulants,  41 — Eating  after  bathing,  42 — Eating 
after  exercise,  43 — Influence  of  carriage  and  dress  on  digestion,  44 — Con- 
stipation and  diarrhea,  48. 


HYGIENE  OF  THE  SKIN   AND  ITS  APPENDAGES. 

By  George  Howard  Fox,  M.  D.,  of  New  York, 

Clinical  Assistant,  Dermatological  Department,  College  of  Physicians  and  Surgeons. 

Anatomy   and  Physiology,  52 — The  epidermis,  52— The  derma, 

54 — The  perspiratory  glands,  54 — The  sebaceous  glands,  57 — The  hair, 
58 — The  nails,  60— Bathing,  60 — The  cold  bath,  61 — The  warm  bath, 
63 — The  hot  bath,  64 — The  proper  time  to  bathe,  64 — Soap,  65 — Medi- 
cated soaps,  66 — Sea-bathing,  66 — The  Turkish  bath,  67 — The  Russian 
bath,  69 — Bath-pruritus,  69 — Care  of  the  complexion,  70 — Clothing,  72 
— For  cold  weather,  74 — For  warm  weather,  75 — Underclothing,  75 — 
Macintoshes,  76 — Shoes,  76 — Soci<s  and  stockings,  79 — Garters,  79 — Cor- 
sets, 80— Bed-clothing,  81— Care  of  the  Hair,  82— Dandruff,  82 — Hair- 
brushes, 83 — Combs,  83 — Shampooing,  84 — Head-gear,  86 — Massage  of 
the  scalp,  87 — Cutting  the  hair,  88 — Dressing  the  hair,  89 — "  Hair-restor- 
ers," 89 — Removal  of  superfluous  hairs,  90 — Hair-dyes,  91 — Care  of  the 
beard,  91 — Shaving,  92 — Care  of  the  nails,  92, 

3 


4      .  TABLE    OF  CONTENTS. 

HYGIENE  OF  THE   VOCAL  AND   RESPIRATORY 
APPARATUS. 

By  E.  Fletcher  Ingals,  M.  D.,  of  Chicago, 

Professor  of  Laryngology  and  Diseases  of  the  Chest  in  Rush  Medical  College. 

The  Nose,  94 — Secretory  sinuses,  96 — The  mucous  membrane,  97 — 
Obstruction  in  the  nasal  passages,  98 — Mouth-breathing,  99 — Causes  of 
nasal  disease,  100 — Catching  cold,  loi — Prevention  of  nasal  catarrh,  102 
— The  Nasopharynx,  104 — Adenoid  growths,  105 — The  Orophar= 
ynx,  106 — The  tonsils,  107 — The  tongue,  107 — The  Larynx,  108 — 
The  vocal  cords,  109 — The  functions  of  the  larynx,  in — The  production 
of  voice-sounds,  112 — The  care  of  the  voice,  113 — Singing,  113 — Exces- 
sive use  of  the  voice,  117 — The  Chest  and  Lungs,  119 — The  thorax, 
120 — The  lungs,  121 — Physiology  of  respiration,  122 — Deformities  of  the 
thorax,  124 — "Shoulder-braces,"  127 — Purification  of  air,  128 — Virulent 
microbes,  129 — Prevention  and  treatment  of  tuberculosis,  129 — Influence 
of  climate  on  consumption,  134 — Division  of  climates,  136 — Description 
of  the  different  climates,  137. 


HYGIENE  OF  THE  EAR. 

By  B.  Alex.  Randall,  M.  D.,  of  Philadelphia, 

Professor  of  Diseases  of  the  Ear  in  the  University  of  Pennsylvania. 

The  External  Ear,  139— The  auricle,  140— "  Ear-rings,"  141 — 
Cleansing  the  meatus,  142 — The  ear-wax,  142 — Impacted  cerumen,  144 — 
Foreign  bodies  in  the  ear,  145 — Itching  of  the  canal,  147 — Exostoses  of 
the  canal,  148 — The  drum-membrane,  149 — "Artificial  ear-drums,"  151 — 
Injuries  and  diseases  of  the  drum-membrane,  152 — The  Middle  Ear, 
155— Eustachian  tube,  156 — Causes  of  most  cases  of  deafness,  157 — 
Suppurative  diseases  of  the  tympanic  cavity,  158 — Ear-ache,  158 — The 
Internal  Ear,  162 — "Nerve-deafness,"  163 — "Noises  in  the  ears" 
(tinnitus  aurium),  163 — Tests  for  hearing,  164 — Ear-trumpets,  168. 


HYGIENE  OF  THE  EYE. 

By  Walter  L.  Pyle,  M.  D.,  of  Philadelphia, 

Assistant  Surgeon  to  Wills  Eye  Hospital. 

General  Description  of  the  Eyeball  and  its  Diseases,  169— 

Advantages  of  binocular  vision,  169 — The  eyebrows,  17 1 — The    eyelids, 
172 — "Black-eye,"  172 — The  eyelashes,  174 — The  tear-apparatus,  176 — 


TABLE    OF  CONTENTS.  5 

The  conjunctiva,  178 — Conjunctivitis,  178 — Halhing  the  eyes,  181 — Gran- 
ular lids,  182 — The  cornea,  183 — The  iris,  184 — The  pupils,  185 — The 
ophthalmoscope,  188 — The  choroid  and  retina,  190 — The  oj)tic  nerve,  192 
— "  Mariotte's  blind  spot,"  193 — Dark  spots  IjtTore  the  eyes,  194 — The 
lens,  194 — Cataract,  195 — "  Second  sight,"  197 — Clauconia,  197 — Injuries 
to  the  eyes,  198 — ^Foreign  bodies,  198- — Burns,  201 — Ametropia  and 
Eye=strain,202 — Emmetropia,  204 — Hyperopia,  204 — Myopia,  205  —  As- 
tigmatism, 205 — Accommodation,  207 — Presbyopia,  209 — Anisometropia, 
209 — Eye-strain,  210 — Symptoms,  2H — The  ocular  muscles,  215 — Muscle- 
deviations,  217 — The  necessity  of  mydriatics,  219 — The  objections  to 
"drops,"  220 — Visual  Tests,  221 — For  acuity  of  vision,  221 — Test- 
cards,  222 — -Testing  accommodation,  224 — Color-blindness,  225 — Tests  for 

blindness,  227— The  General  Care   of   the   Eyes  and  School^ 

hygiene,  228 — Infants'  eyes,  228 — Dangers  of  the  kindergarten,  229 — 
Care  of  school-children's  eyes,  230 — School-hygiene,  232 — The  school- 
building,  234 — The  school-room,  235 — Desks  and  seats,  235 — School- 
books,  241 — Printing,  241 — Writing,  243 — Over  work  of  the  eyes,  244 — 
Artificial  lighting,  244 — Kerosene,  247 — Illuminating-gas,  247 — Electric- 
ity, 248 — Acetylene,  250 — Prismatic  devices,  250 — Hygienic  precautions, 
in  reading,  252 — Wearing  veils,  255 — Effects  of  smoking  and  drinking, 
256 — Relation  of  the  eyes  to  the  general  health,  256 — Spectacles  and 
Eye=glasses,  257 — Invention,  257 — Province  of  the  optician,  257 — 
Spectacles,  259 — Flitting  and  care,  260 — Eye-glasses,  265 — Bifocal  lenses, 
265 — Trifocals,  267 — Pantoscopic  spectacles,  267 — Lorgnettes,  268 — Tinted 
glasses,  268 — Prejudice  against  wearing  glasses,  269 — Early  discomfort, 
271 — Necessity  of  changing,  273 — Artificial  eyes,  273. 


HYGIENE  OF  THE  BRAIN   AND  NERVOUS  SYSTEM. 

By  J.  W.  Courtney,  J\I.  D.,  ok  Boston, 

Physician  for  Diseases  of  the  Nervous  System,  Boston  City  Hospital. 

General  Principles,  275 — Nervous  tissue,  275 — The  central  nervous 
system,  275 — Analogy  to  telegraphy,  275 — Influences  of  heredity,  educa- 
tion, and  environment,  276 — "  Born  degenerate,"  276 — Prenatal  influences, 
278 — Nervous  and  mental  hygiene  in  childhood,  279 — The  school-going 
age,  279 — After  the  age  of  twelve,  280 — Puberty  and  its  attendant  dangers, 
280 — Duties  of  parents  and  teachers,  28 1 — Neurasthenia,  2S2 — Gen- 
eral remarks,  282 — Definition,  283 — Causation,  283 — Symptoms,  285 — ■ 
Pathology,    2S9 — Prognosis,    290 — Hygienic    treatment,    290 — Abuse    of 


6  TABLE    OF  CONTENTS. 

alcohol,  coffee,  tea,  and  tobacco,  292 — Over=work,  293 — "  Curve  of 
health,"  293 — Mental  over-work,  294 — Worry,  297 — Need  of  mental 
recreation,  298 — Physical  over-work,  300 — Regulated  exercise,  304 — Golf, 
305 — Bicycling,  306 — Tennis,  307 — Canoeing  and  boating,  307 — Hunting, 
307 — Sleep,  308 — Physiologic  consideration 3,309 — Insomnia,3ii — Treat- 
ment, 312 — Conclusion,  314. 


PHYSICAL  EXERCISE. 

By  G.  N.  Stkwart,  M.  D.  (Edin.),  of  Chicago, 

Professor  of  Physiology  in  the  University  of  Chicago. 

Physiology  of  Muscular  Movement,  315— Spontaneous  move- 
ment, 315 — The  muscles,  315 — Skeletal  muscles,  316 — Striped  muscles, 
^16 — Unstriped  muscles,  316 — Muscular  contraction,  316 — Nerve-impulse, 
317 — Voluntary  movements,  319 — Automatic  movements,  319— Reflex 
movements,  320 — Work  done  by  muscular  contraction,  320 — Transforma- 
tion of  food-substances  into  muscular  energy,  321 — Consumption  of  glu- 
cose, 322 — Consumption  of  glycogen,  322 — The  nitrogenous  substances, 
322 — The  Effects  of  Muscular  Exercise,  323 — Fatigue  of  muscles, 

323 — Restorative  properties  of  food-substances,  325 — Sugar,  325 — Fats, 
325 — Caffein,  325 — Alcohol,  326 — Production  of  waste-substances,  326 — 
Effect  of  muscular  contraction  on  the  flow  of  blood,  326 — Effect  of  exer 
cise  on  the  heart,  327 — On  respiration,  328 — On  the  skin,  329 — On  the 
digestive  system,  329 — Physical  Training,  329 — Association  with  men- 
tal training,  329 — Kind  of  exercise  most  advantageous,  331 — Physical 
training  in  childhood,  332 — In  youth,  333 — In  adult  life,  333 — Sports  and 
gymnastics,  334 — "  Swedish  movements,"  335 — Amount  of  exercise  re- 
quired, 335 — Excessive  exercise,  336 — Exercise  in  disease,  337 — Honie= 
Gymnastics,  338 — Importance  of  gymnastics,  338 — Training  of  the 
abdominal  muscles,  336 — General  rules  for  exercises,  339 — Stretching 
exercises,  341 — Dumb-bell  exercise,  341 — Breathing  exercise,  342— Twist- 
ing exercise,  343 — Shrug-movement,  344 — Forward  and  backward  bend, 
344 — Side  bend,  345 — Windmill  movements,  345 — Floor-exercises,  346— 
Relaxing  exercises,  347— Knee,  347— Hip,  347 — Shoulders,  348. 


TAliLK    OF  CONTENTS.  'J 

DOMESTIC  HYGIENE. 

By  ]).  II.   1!|'.r<;|':y,  M.  1).,  of  I'iiii.adkii'iiia, 

First  Assistant  in  tin;  Luljoratory  of  Hygiene  and  Assistant  Professor  of  Bacteriology 
in  the  University  of  Pennsylvania. 

General  Remarks,  349— Construction  and  Location  of 
Dwellings,  350 — Location,  350 — Elevation,  350 — Soullicrn  exposure, 
350 — Fmuulalion  and  walLs,  351 — Roof,  352 — Internal  arrangement, 
352 — Height,  352 — Size  of  rooms,  352 — Cellar,  353 — Kitchen,  354 — Re- 
frigerator, 354 — Stairways,  354 — Hallways,  354— Draperies,  354 — Cur- 
tains, 354 — Doors,  354 — Windows,  354 — Walls  and  wall-coverings,  355 — 
Floors  and  floor-coverings,  356 — Ventilation,  357 — Relative  proportion 
of  carbon  dioxid,  357 — Methods  of  estimating,  358 — Odor  of  organic  mat- 
ter, 359— Excess  of  humidity,  359 — Natural  ventilation,  360 — Artificial 
ventilation,  361 — Heating,  361 — Direct  and  indirect,  362 — Combined 
system  of  ventilation  and  heating,  362 — Furnace-heating,  362 — Excessive 
temperature,  363 — Dryness  of  the  air,  364 — Dust,  364 — Devices  for  cool- 
ing the  air,  364— Water=SUppIy,  366— Purity,  366— Municipal  water- 
works, 367 — Filtration,  367 — Domestic  filters,  36S  —  Plumbing  and 
Drainage,    369 — Sewers    and    drains,    369 — Traps,    370  —  Waste-pipes, 

371— Sewer-gas,  372— Cess-pools,  372— Modern  Bath^rooms  and 
Toilet=rooms,  372 — Water-closets,  373 — Flush  tanks,  374 — Water- 
waste  preventers,  374 — Disposal  of  Garbage  and  Ashes,  374 — Garb- 
age, 374 — Ashes,  375^Nuisances,  375 — Foul  odors,  375 — Noxious 
fumes,  376 — Noises,  376 — Dust,  376 — Smoke  and  soot,  377  —  House~ 
cleaning,  378 — Sweeping,  379 — Purifying  agents,  379 — Washing  and 
laundering,  379 — Clothes-cleaning,  380 — Clothes-disinfection,  380 — Food 
and  Dietetics,  381 — Nutritive  value  and  cost  of  foods,  382— Vegetarian 
diet,  384 — Cooking,  384 — Adulteration  of  foods,  385  — Food  as  a  cause  of 
infectious  diseases,  385 — Inspection  of  meats,  386 — Inspection  of  milk, 
387— Causes  and  Transmission  of  Disease,  389 — Physical  causes, 
389 — Vital  causes,  389 — Chemic  causes,  390 — Transmission  of  infectious 
diseases,  390 — Insects  and  vermin,  390 — Isolation  and  disinfection,  391 — 
Individual  susceptibility,  392 — Environment,  392 — Heredity,  393 — Hy- 
giene of  the  sick-room,  393 — House-quarantine,  394 — Period  of  detention, 
395 — Special  precautions  against  typhoid  fever,  398 — Small-pox,  399. 


TABLE    OF  CONTENTS. 


APPENDIX. 


Pulse,  Temperature,  and  Respiration,  401 — Pulse,  401 — Tem- 
perature, 402 — Clinical  thermometer,  402 — Respiration,  403  —  Baths, 
403 — Temperature,  403  —  Hot-baths,  403  —  Hot  foot-baths,  404 — Hot- 
vapor  baths,  404 — Hot-air  bath,  405 — Acid  steam-bath,  406 — Sheet-bath, 
406 — Drip-sheet,  406 — Cold  douche,  407 — Cold  pack,  407 — Hot  pack, 
407 — Partial  packs,  408 — Massage,  409 — Movements,  409 — Method, 
410 — Accidents  and  Emergencies,  411 — Cut  and  incised  wounds, 
411 — Lacerated  wounds,  412 — Punctured  wounds,  412 — Fish-hook 
wounds,  412 — Splinters,  413 — Insect-stings,  413 — Mosquito-bites,  413 — 
Dog-bites,  413 — Snake-bites,  413 — Ivy-poisoning,  414 — Bruises  and  con- 
tusions, 414— Sprains,  414 — Fractures,  415 — Dislocations,  415 — Hand- 
kerchief-bandages, 415 — Four-tailed-bandages,  415 — Burns  and  scalds, 
416 — Household  conflagrations,  417 — Inhalation  of  steam,  418 — Frost- 
bite and  freezing,  420 — Sunstroke,  420 — Heat-exhaustion,  420 — Lightning- 
stroke,  421 — Electrical  injuries,  421 — Drowning,  421 — Artificial  respiration, 
421 — Asphyxiation, 423 — Head-injuries,  424— Epileptic  convulsions,  424— 
Convulsions  in  children,  424 — Hemorrhage  of  lungs,  425— Bleeding  from 
thestomach,425— Nose-bleed,  425— Poisoning,  425 — Household  poisons, 
425— First  treatment,  425 — Stomach-pump,  426 — Irritant  poisons,  426 — 
Acids  and  alkalis,  426 — Narcotics,  427 — Opium  poisoning,  428— Bella- 
donna, 428 — Alcohol,  428— Prussic  acid,  428— Strychnin,  429 — Rat- 
poison,  429— Table  of  Poisons  and  Antidotes,  429. 


Glossary 43^ 

Index , 441 


A  MANUAL  OF  PERSONAL  HYGIENE. 


HYGIENE  OF  THE  DIGESTIVE  APPARATUS. 

By  CHARLES   G.    STOCKTON,   M.  D., 

OF    BUFKALO. 

Professor  of  Medicine  in  the  Medical  Department  of  the  University  of  Buf- 
falo;  Attending  Physician  to  the  Buffalo  General  Hospital. 


PHYSIOLOGY  OF   DIGESTION. 

Mastication  and  Insalivation. — Digestion  begins 
in  the  mouth  with  the  mastication  and  insalivation 
of  the  food.  Upon  the  thoroughness  of  the  mastica- 
tion, the  disintegration  of  the  larger  and  more  resist- 
ing morsels  and  the  thorough  admixture  of  them  with 
the  saliva,  depends  in  no  small  degree  the  comfort 
with  which  the  gastric  digestion  is  carried  out. 
Starchy  foods  in  particular  require  the  effect  of  the 
ptyalin,  a  constituent  of  the  saliva,  by  the  action  of 
which  the  starch,  especially  when  thoroughly  cooked, 
is  converted  into  maltose.  The  saliva  escapes  into  the 
mouth  from  three  separate  sets  of  salivary  glands 
— the  parotid  at  tlie  angle  of  the  jaw,  the  submaxil- 
lary along  the  side  of  the  tongue,  and  the  sublingual 
under  the  tongue.  The  mouth  is  further  moistened 
by  the  secretion  of  the  mucous  membrane  with  which 
it  is  lined.  The  salivary  secretion  is  excited  by  the 
presence  of  foreign  bodies  in  the  mouth,  but  especi- 
ally by  food.     The  action  of  the  glands  is  controlled 

9 


lO 


THE  DIGESTIVE  APPARATUS. 


by  the  nervous  system,  and  the  effect  of  the  higher 
nervous  centers  upon  their  activity  may  be  instanced 
in  the  free  flow  of  saliva  that  follows  the  odor  of  cer- 


Salivary  {Parotid) 
gland 


Salivary 
glands 


Duodenum 


Large  intes- 
tine 


S}nall  intes- 
tine 


Rectutn 
Vermiform  appendix " 
Fig.  I.— General  scheme  of  the  digestive  tract,  with  the  chief  glands  open- 
ing into  it. 

tain  substances,  and  the  sight,  or  even  thought,  of 
others.  The  saliva  is  slightly  alkaline  in  reaction, 
and  its  activity  differs  in  different  individuals. 


THE   STOMACH.  II 

The  conversion  of  starch  into  maltose  by  ptyalin  is 
diminished  in  the  presence  of  a  slightly  acid  medium, 
and  ceases  in  a  free  acid  medium.  If  the  saliva  is  di- 
luted by  water  or  other  fluids,  its  activity  is  correspond- 
ingly diminished.  Therefore  foods  should  only  be 
swallowed  after  they  are  thoroughly  disintegrated  by 
the  teeth  and  sufficiently  liquefied  by  the  saliva  to 
pass  easily  through  the  esophagus  without  the  assist- 
ance of  drink. 

The  stomach  is  a  muscular  sac,  lying  for  the  most 
part  on  the  left  side  of  the  body  and  under  the  ribs. 
Its  entrance,  at  the  termination  of  the  esophagus,  is 
called  the  cardia,  and  is  guarded  by  an  increase  in 
the  circular  muscle-fibers,  by  the  contraction  of  which 
the  opening  is  closed  at  the  proper  interval.  Its  out- 
let into  the  duodenum  is  called  the  pylorus,  and  this 
also  is  guarded  by  circular  muscle-fibers,  which  close 
the  opening  so  as  to  prevent  the  untimely  escape  of 
the  gastric  contents.  The  stomach  is  covered  with  a 
delicate  serous  coat,  a  part  of  the  peritoneum,  and  is 
lined  with  a  mucous  membrane.  In  the  adult  the 
stomach,  when  filled,  contains  from  two  to  three 
pints  or  more.  It  varies  considerably  in  size  and 
shape  in  healthy  individuals.  It  is  very  richly  sup- 
plied with  blood-vessels  and  lymphatics;  and  the 
veins  empty  into  the  portal  system  going  to  the  liver, 
not  communicating  directly  with  the  general  circula- 
tion. The  mucous  membrane  secretes  large  quanti- 
ties of  fluid  called  gastric  juice,  which  contains 
hydrochloric  acid,  and  two  ferments  called,  respec- 
tively, pepsin  and  rennet,  or  lab-ferment.  The  acid 
is  mostly  secreted  toward  the  cardiac  end  of  the  stom- 
ach and  the  ferments  near  the  pyloric  end.     During 


12  THE  DIGESTIVE  APPARATUS. 

fasting  the  stomach  is  of  a  pale-pink  color,  and  con- 
tains a  small  amount  of  fluid  neutral  in  reaction. 
With  the  introduction  of  food  the  mucous  membrane 
becomes  of  a  deeper  red  color  and  the  secretion  be- 
comes very  abundant.  As  this  secretion  is  acid  in 
reaction,  it  might  be  supposed  that  the  digestion  of 
starch,  begun  in  the  mouth,  would  immediately  cease 
in  the  stomach.  Such,  however,  is  not  the  case, 
owing  to  the  fact  that  the  earlier  secretion  of  hydro- 
chloric acid  promptly  combines  with  the  albumin  in 
the  foods,  so  that  free  hydrochloric  acid  is  for  a  time 
not  present.  A  slight  amount  of  lactic  acid  is  found  at 
this  time;  but  it  mostly  comes  preformed  in  the  food, 
and  is  not  the  result  of  secretion,  although  to  some 
extent  it  may  come  from  fermentation  even  in  the 
healthy  stomach.  After  a  certain  period  of  time, 
varying  in  individuals  from  a  few  minutes  to  a  few 
hours,  the  secretion  of  hydrochloric  acid  is  in  excess 
of  that  which  may  combine  with  the  albumin;  and  it 
therefore  appears  as  a  free  acid,  at  which  time  the 
trace  of  lactic  acid  disappears.  As  a  result  of  the  in- 
creased acidity,  the  digestion  of  starches,  for  the  time 
being,  comes  to  an  end.  On  the  other  hand,  the  so- 
lution of  the  albumins,  their  conversion  into  peptones, 
and  the  breaking  up  of  the  covering  of  the  fat-cells 
proceed  rapidly.  The  cellulose  of  vegetables  and 
fruits  is  broken  up,  and  the  absorption  of  certain  con- 
stituents of  the  stomach-contents  begins.  All  of 
these  matters  are  greatly  favored  by  the  muscular 
action  of  the  stomach,  which  by  slow  wave-like 
contractions  (the  cardia  and  the  pylorus  being  closed) 
thoroughly  mingle  the  gastric  contents  and  assist  in 
their  solution  and  absorption.     From   time  to  time 


y///-;   SMALL    INTKS'LJNK.  I  3 

the  better  digested  portions  pass  throiigli  the  pylorus; 
but  the  solid  particles  stimulate  pyloric  contraction, 
and  their  escape  into  the  intestine  is  therefore 
properly  prevented.  After  the  lapse  of  from  four  to 
seven  hours  the  gastric  digestion  is  practically  com- 
pleted, the  organ  having  gradually  emptied  itself,  and 
at  length  the  pylorus  relaxes  sufficiently  to  allow  the 
more  insoluble  remains  to  pass  into  the  intestine. 

Absorption  from  the  stomach  is  of  less  impor- 
tance than  was  formerly  supposed.  The  alcohols, 
salts,  certain  extractive  matters,  and  pure  water  may 
be,  and  to  some  extent  usually  are,  absorbed  directly 
from  the  stomach;  but  water  in  the  presence  of  solid 
foods  or  blended  with  foods,  as  in  soup,  is  apparently 
not  so  absorbed.  A  glassful  of  pure  water  is  found  to 
have  left  the  stomach  after  a  quarter  or  half  of  an 
hour,  but  when  taken  with  food  it  escapes  with  the 
latter  in  the  ordinary  course  of  digestion.  The  office 
of  the  stomach,  like  that  of  the  mouth,  is  to  prepare 
the  food  for  its  final  digestion  in  the  intestine.  The 
stomach  has  a  very  complex  nerve-supply  that  gov- 
erns its  activity,  and  it  is  therefore  subject  to  derange- 
ments that  follow  nervous  excitation  in  various  other 
parts  of  the  organism. 

The  Small  Intestine. — The  intestine  is  described 
as  consisting  of  two  divisions,  a  small  and  a  large  in- 
testine. The  small  intestine  is  about  twenty  feet  long 
in  the  adult,  and  is  subdivided  into  three  portions: 
the  duodenum,  extending  from  eight  to  ten  inches 
beyond  the  pylorus;  the  jejunum,  which  forms  two- 
fifths;  and  the  ileum,  three-fifths  of  the  remainder  of 
the  small  intestine.  Like  the  stomach,  the  intestine 
is  lined  by  a  mucous  membrane,  with  columnar  epithe- 


14  THE  DIGESTIVE   APPARATUS. 

Hum,  and  thickly  set  with  secreting  glands.  It  has 
a  very  vascular  submucosa  and  is  rich  in  lymphatics. 
A  muscular  coat  arranged  partly  in  circular  and  partly 
in  longitudinal  fibers  lies  outside  of  the  submucosa. 
Finally,  like  the  stomach,  it  is  clothed  with  a  serous 
membrane  continuous  with  the  lining  of  the  peritoneal 
cavity.  Between  the  muscular  coats  is  arranged  a 
system  of  fine  nerves  (Auerbach's  plexus)  which 
preside  over  the  movements  of  the  intestine.  In  the 
submucous  coats,  extending  from  the  stomach  to  the 
anus,  are  distributed  the  fibers  of  the  nerves  of  se- 
cretion (Meissner's  plexus).  These  nerves  are  pro- 
vided with  ganglion-cells,  and  it  is  probable  that  these 
are  the  centers  that  control  the  circulation,  excretion, 
and  secretion  of  the  intestine.  The  surface  of  the 
mucous  membrane  of  the  stomach  is  enormously 
increased  through  the  presence  of  the  valvulse  con- 
niventes  and  the  villi.  The  former  appear  as  nu- 
merous transverse  folds  projecting  into  the  lumen  of 
the  intestine,  and  they  interrupt  and  retard  the  cur- 
rent of  the  intestinal  stream.  Like  other  portions  of 
the  intestinal  mucous  membrane,  they  are  covered 
with  villi,  one  or  two  lines  in  length,  so  closely  ar- 
ranged that  they  project  from  the  surface  somewhat  in 
the  manner  of  fur.  Between  the  villi  are  placed  three 
kinds  of  glands  differing  somewhat  in  character  and 
distribution.  The  tubular  depressions  of  the  mucous 
membrane,  called  the  glands  of  LieberkiJhn,  extend 
throughout  both  the  large  and  small  intestines,  in- 
creasing in  size  as  they  approach  the  anus.  Brun- 
ner's  glands  are  confined  to  the  duodenum.  They  are 
placed  in  the  submucosa  and  have  excretory  ducts; 
in  structure  and  function  they  resemble  the  pyloric 


biGlLSriON  /N   THE   rNTESTINE.  I5 

glands  of  the  stomach.  The  glands  of  Peyer  occur 
ill  the  small  intestine,  but  are  most  abundant  in  the 
lower  portion  of  the  ileum.  vSometimes  they  are 
single,  sometimes  in  clusters,  when  they  are  termed 
"agminate"  glands,  or  Peyer's  patches. 

Accessory  Digestive  Organs. — The  liver  occupies 
a  position  on  the  right  side  of  the  body  clo.sely  corre- 
sponding to  that  occupied  by  the  stomach  on  the  left. 
It  moves  with  the  diaphragm  in  respiration,  and  its 
secretion  of  bile  passes  in  part  temporarily  into  the 
gall-bladder,  where  it  is  stored  until  needed,  but 
eventually  is  discharged  through  the  common  bile- 
duct  into  the  duodenum,  near  the  outlet  of  the  excre- 
tory duct  of  the  pancreas.  The  latter  organ,  lying 
transversely  across  the  abdomen,  below  and  behind 
the  stomach,  secretes  a  juice  most  important  in  the 
chemistry  of  digestion.  In  some  respects  it  resembles 
the  saliva  in  that  it  converts  starch  into  maltose;  but 
it  is  far  more  complex,  and  possesses  a  second  ferment 
that  digests  albumin,  and  a  third  that  emulsifies  fats. 
The  pancreatic  juice,  the  bile,  and  the  secretion  of 
the  glands  of  the  intestine  are  alike  alkaline  in  re- 
action. The  bile  may  be  regarded  as  an  adjuvant  in 
intestinal  digestion,  although  it  also  contains  waste 
matter  cast  off  by  the  liver  from  the  blood. 

Digestion  in  the  Intestine. — Of  the  secretions  of 
the  small  intestine,  that  coming  from  the  duodenum 
is  the  most  important  in  its  chemic  action  on  food. 
The  stomach-contents  entering  the  intestine  in  the 
form  of  chyme  are  sharply  acid  in  reaction,  owing  to 
free  hydrochloric  acid,  and  are  semifluid  or  fluid  in 
consistency.  Chyme  does  not  pass  rapidly  down  the  in- 
testine, but  its  course  is  delayed  through  the  interven- 


1 6  THE  DIGESTIVE  APPARATUS. 

tion  of  the  valvulse  conniventes  and  villi.  It  is  soon 
rendered  alkaline  by  the  action  of  the  intestinal  secre- 
tion, the  bile,  and  the  pancreatic  juice.  These  vari- 
ous secretions  at  once  take  up  the  role  of  digestion, 
the  albumin  being  still  further  converted  into  pep- 
tone, and  the  starches  into  maltose,  and  cane-sugar 
into  glucose,  while  the  fats  are  emulsified.  Absorp- 
tion may  begin  through  the  activity  of  the  veins  and 
lacteals  with  which  every  villus,  as  well  as  other 
parts  of  the  mucosa,  is  provided.  When  prepared, 
the  available  nutriments  are  absorbed  from  the  intes- 
tinal contents  through  a  process  of  selection,  while 
certain  harmful  matters  are  discharged  through  the 
excretion  of  the  glands.  It  is  thus  seen  that  there  is 
a  more  or  less  continuous  interchange  of  fluids  be- 
tween the  intestine  and  the  blood-vessels.  The  veins 
from  the  intestine  discharge  themselves  through  the 
branches  of  the  portal  veins  into  the  liver  ;  the  lym- 
phatics, carrying  much  of  the  fat,  empty  themselves 
into  the  thoracic  duct,  and  ultimately  into  the  great 
central  vein,  or  the  vena  cava.  The  blood  from  the 
stomach  and  intestines,  freighted  with  aliment,  passes 
to  the  liver,  where  the  various  substances  are  further 
modified  and  refined  before  their  final  reception  into 
the  systemic  veins  of  the  body. 

The  Large  Intestine. — The  small  intestine  is 
guarded  by  the  ileocecal  valve  where  it  communi- 
cates with  the  large  intestine.  The  latter  is  about 
four  to  six  feet  long  in  the  adult,  and  is  divided  into 
three  portions:  the  cecum,  a  short  and  relatively 
wide  pouch,  which  has  the  vermiform  appendix  and 
communicates  with  the  colon,  the  principal  part  of 
the  large  intestine.     The  colon  has  an  ascending,  a 


HYGIKNE    OF   'J 'I IE    TEETH.  I J 

transverse,  and  a  descending  portion.  The  last- 
named,  located  on  the  left  side  of  the  abdomen,  bends 
to  form  the  sigmoid  flexure,  and  finally  reaches  the 
rectum,  which  terminates  in  the  anus.  It  is  the 
office  of  the  large  intestine  to  retain  the  waste  matter 
and  overflow  from  the  small  intestine,  and  to  hold  the 
feces  until  its  liquid  portions  are  sufficiently  absorbed. 
The  sigmoid  flexure  acts  as  a  valve  and  prevents  the 
descent  of  the  feces  into  the  rectum  until  the  act  of 
defecation  occurs.  The  feces  should  then  be  of 
proper  consistency,  and  through  contraction  of  the 
colon  are  discharged  from  the  descending  portion  into 
the  rectum,  and  with  the  assistance  of  the  abdominal 
muscles  and  those  of  the  rectum  complete  the  process 
of  evacuation. 

HYGIENE  OF  THE  TEETH. 

Deformities. — As  the  result  of  inherited  peculi- 
arities the  teeth  are  sometimes  too  large  in  proportion 
to  the  length  of  the  jaws,  and,  as  a  result,  they  are 
forced  out  of  line,  and  are  crowded  against  each  other, 
so  that  it  is  difficult  to  give 
them  proper  care.  Such  de- 
fects occasionally  result  from 
the  too  frequent  habit  of 
mouth-breathing,  a  practice 
that  commonly  follows  ob- 
struction   to    the    nasal   pas-  ^ 

sages  through  hypertrophy  FiG.2.-Deformi^of  the  teeth 
of    the    adenoid    tissue    in    the        caused  by  mouth-breathing. 

vault    of    the    pharynx    (see 

page    98.)       The  deformity  referred   to  consists  in 

narrowing   of    the    hard   palate   and    the    maxillary 

2 


l8  THE  DIGESTIVE  APPARATUS. 

arch,  so  that  the  line  of  the  incisor  teeth  above 
project  some  distance  beyond  the  line  of  the 
lower  incisors,  as  illustrated  in  Fig.   2.     The  lower 


Fig.  3. — Asymmetry  of  the  face  due  to  a  receding  lower  jaw,  the  result  of 
mouth-breathing. 

jaw  is  apt  to  recede,  and  the  symmetry  of  the 
face  is  thereby  disturbed  as  shown  in  Fig.  3.  Fig. 
4  shows  the  same  face  in  which   the  lower  jaw  is 


Fig.  4.^Lower  jaw  brought  forward  into  its  proper  position. 

brought  forward  in  its  proper  position.  A  deformity 
somewhat  resembling  this  results  from  the  habit  of 
"thumb-sucking."     In  this  condition  the  upper  in- 


JIYGIKNK    OF   TJIK    TKETJI.  1 9 

cisors  are  directed  outward  and  the  lower  incisors 
somewhat  inward,  as  ilhistrated  by  Fi<^.  5.  The 
habit  of  breathing  through  the  mouth  is  commonly 
associated   with    that   of   "thumb-sucking."      From 


liiHllii,ll,„iJilut  ™i(i|iuiiii>i'»        '•*' 

Fig.  5. — Deformity  caused  by  thumb-sucking  (Darby). 

whatever  cause  arising,  habitual  breathing  through 
the  mouth  leads  to  the  accumulation  of  organic  mat- 
ter about  the  teeth  and  thus  favors  the  destruction 
of  dentin'.  Certain  families  through  several  genera- 
tions have  soft  or  feeble  teeth,  apparently  because  of 
some  congenital  disturbance  in  the  nutrition  of  the 
parts.  It  is  commonly  believed  that  in  such  individ- 
uals much  more  care  is  required  to  prevent  the  devel- 
opment of  caries.  These  poorly  developed  teeth  are 
sometimes  seen  in  scorbutic  or  rachitic  children,  and 


Fig.  6. — Teeth  in  congenital  syphihs. 

in  those  suffering  from  congenital  syphilis;  but  the  con- 
dition is  also  present  in  those  wdio  in  other  respects  ap- 
pear to  enjoy  good  health.  In  congenital  syphilis  the 
secondary  teeth  are  affected  in  a  characteristic  way 


20  THE  DIGESTIVE  APPARATUS. 

(Fig.  6).  The  incisors  are  peg-shaped,  notched,  and 
sometimes  placed  at  such  an  angle  that  their  cutting 
edges  are  found  to  meet.  Many  cases  of  irregular 
eruption  of  the  teeth  are  improperly  attributed  to 
syphilis,  and  the  same  may  be  said  of  the  notching 
that  occurs  along  the  teeth  of  many  fairly  healthy 
children — irregularities  not  identical  with  the  peculi- 
arities pointed  out  by  Jonathan  Hutchinson. 

Causes  of  Decay. — It  is  commonly  believed  that 
in  the  matter  of  resistance  and  external  irritation  the 
teeth  of  certain  individuals  are  naturally  faulty. 
Even  when  the  teeth  receive  reasonably  intelligent 
care  the  development  of  caries  is  a  constant  source  of 
anxiety;  on  the  other  hand,  in  certain  families,  and 
particularly  in  certain  races,  the  teeth  are  naturally 
strong  and  are  often  retained  until  old  age — even 
when  they  receive  no  further  care  than  that  which 
comes  from  vigorous  use  in  the  mastication  of  coarse 
and  resisting  foods.  A  like  difference  may  be  noted 
in  the  integument  of  people,  and  may  be  explained 
by  assuming  that  this  depends  upon  some  peculiarity 
in  nutrition.  The  form  of  diet  has  been  thought 
by  some  to  be  a  factor  in  caries  of  the  teeth.  It  has 
been  noticed  that  the  teeth  that  are  least  called  upon 
for  mastication  are  often  the  most  delicate.  Strong 
and  resisting  teeth  seem  to  come  naturally  to  those 
who  live  upon  coarse  foods.  Apparently  the  innerva- 
tion and  blood-supply  is  better  in  healthy  individuals 
who  use  their  teeth  somewhat  severely. 

While  common  observation  teaches  that  the  devel- 
opment of  caries  depends  in  part  upon  the  suscepti- 
bility of  the  teeth  of  certain  individuals,  this  fact  has 
been    denied,    and    apparently    with    some    reason. 


CAUSES   OF  DECAY   OF    'J HE    TEETH.  21 

Black,  of  Indiana,  subjected  a  large  number  of  ex- 
tracted teeth  to  a  great  variety  of  tests,  including  their 
exposure  for  varying  periods  to  the  action  of  chemicals 
and  to  the  attacks  of  bacteria.  When  these  teeth  were 
subsequently  examined  by  the  most  careful  methods, 
there  was  seen  to  be  practically  no  difference  in  the 
resistance  that  they  had  shown.  Strong  and  feeble 
teeth  were  affected  alike,  and  it  may  be  inferred  that 
poor  teeth  do  not  differ  materially  from  those  that  are 
usually  regarded  as  strong  in  their  resistance  to  the 
influences  that  produce  decay. 

The  old  opinion  that  the  teeth  are  injuriously 
affected  through  the  action  of  certain  acids  found  in 
the  stomach  is  also  disappearing.  Miller,  who  found 
more  than  one  hundred  varieties  of  micro-organisms 
that  grew  in  the  mouth  or  about  the  teeth,  believes 
that  caries  is  the  result  of  lactic  acid  produced  by  the 
growth  of  certain  of  these  bacteria.  It  is  now  generally 
accepted  that  the  bacteria  are  in  some  way  responsible 
for  dental  caries;  but  there  is  a  growing  doubt  as  to 
lactic  or  other  acids  playing  any  special  part  in 
this  process.  Hopkins,  of  Harvard,  has  taken  up 
the  question,  and  has  shown  that  in  these  micro- 
organisms, of  which  he  has  found  about  fifty  varieties 
commonly  present  in  diseased  teeth,  about  one-fifth 
of  the  number  were  producers  of  lactic  acid,  but  the 
strongest  proportion  of  acid  that  he  was  able  to  pro- 
duce by  the  growth  of  these  bacteria  was  o.  5  per  cent. 
He  subsequently  found  that  if  teeth,  good  and  poor 
alike,  were  subjected  to  a  solution  of  lactic  acid  in 
the  strength  'of  0.5  per  cent,  for  a  period  of  four 
months,  no  carious  action  whatever  could  be  dis- 
covered.    The  observer  emphasizes  a  fact,  previously 


22  THE  DIGESTIVE  APPARATUS. 

known,  that  some  of  the  organisms  that  are  appar- 
ently destructive  give  rise  to  secretions  alkaline  rather 
than  acid  in  reaction.  It  has  been  commonly  observed 
that  some  mouths  in  which  caries  is  conspicuous 
show  a  free  secretion  of  saliva  and  a  constant  alkaline 
reaction.  Much  has  yet  to  be  learned  about  the  mat- 
ter; but  it  may  be  assumed  that  to  bacteria  we  must 
attribute  dental  decay;  that  the  question  of  natural 
resistance  of  the  teeth  plays  but  a  subordinate  part; 
and  that  the  character  of  the  diet,  so  long  as  it  is  suf- 
ficiently nutritious,  has  not  been  shown  to  have  any 
influence  whatever.  When  fragments  of  food,  to- 
gether with  the  secretions  of  the  mouth,  find  lodge- 
ment between  and  around  the  teeth  there  is  afforded 
an  opportunity  for  the  growth  and  development  of 
bacteria.  Some  idea  of  the  number  of  these  organ- 
isms may  be  inferred  from  what  has  been  said.  It  is 
believed  that  micro-organisms  are  concerned  in  the 
formation  of  the  discolored  tartar  so  disfiguring  to  the 
teeth  and  injurious  to  the  gums.  But  teeth  are  at- 
tacked and  cavities  are  formed  without  the  develop- 
ment of  tartar;  all  that  seems  necessary  is  for  the  or- 
ganism to  find  a  lodgement  in  some  protected  place 
where  they  are  removed  from  the  action  of  the  tooth- 
brush and  other  toilet  articles  commonly  used  to  dis- 
lodge them.  Catarrhal  irritation  about  the  margin  of 
the  gums  leads  to  their  recession  and  exposure  of  the 
teeth  where  they  are  unprotected  by  enamel.  This 
catarrhal  condition  is  due  in  large  part  to  the  action 
of  bacteria,  but  the  condition  is  much  favored  by  the 
continual  irritation  from  tobacco  and  acrid  foods,  also 
by  the  presence  of  tartar  and  by  carelessness  in  the 
use  of  tooth-brushes,  tooth-picks,  and  the  like. 


PRF.SlikVATJON    OF    ■Jill':    'J/:1:J'JI.  23 

A  disease  of  iiiiich  iiiiportaiiee  that  occasionally  af- 
fects the  giiuis  is  known  as  pyorrhcea  alveolaris, 
commonly  called  Rii^^gs'  disease.  This  was  at  one 
time  believed  to  depend  upon  a  constitutional  condi- 
tion, and  in  some  way  to  be  associated  with  the  so- 
called  uric-acid  diathesis.  This  view  never  seemed 
logical,  and  is  overthrown  by  recent  study.  Un- 
doubtedly, as  in  the  case  of  other  infections,  perfect 
systemic  health  is  the  best  safeguard  against  infec- 
tion, but  that  good  general  health  can  prevent  the 
development  of  bacteria  is  untenable.  Younger,  of 
Chicago,  regards  the  disease  as  essentially  of  bacterial 
nature,  and  views  injury  to  the  gums,  and  especially 
the  perforation  of  the  peridental  membrane,  as  the 
first  step  in  its  process.  Such  injuries  are  usually 
produced  by  the  forcible  introduction  between  the 
gum  and  tooth  of  hard  foreign  bodies,  like  seeds  of 
berries,  bits  of  bone,  and  bristles  from  the  tooth-brush. 

Preservation  of  Teeth. — From  what  has  been  said 
it  may  be  concluded  that,  so  far  as  we  understand  the 
matter,  the  preservation  of  the  teeth  resolves  itself 
into  a  few  simple  principles;  namely,  the  prevention 
of  overcrowding,  the  avoidance  of  chemical  or  me- 
chanical injury  to  the  teeth  and  gums,  the  careful  and 
frequent  cleansing  of  all  the  exposed  surfaces  of  the 
teeth,  and  the  use  of  such  harmless  antiseptics  as  will 
prevent  the  long  continuance  of  pathogenic  bacteria 
in  the  mouth.  The  most  easily  available  means  of 
protection  lies  in  the  proper  cleansing  of  the  teeth. 
For  this  purpose  the  frequent  use  of  the  tooth-brush 
is  indispensable.  The  ordinary  bristle  brush  has  been 
opposed  on  the  ground  that  it  is  too  hard  and  is  liable 
to  injure  the  gums,  particularh'  when  stray  bristles 


24  THE  DIGESTIVE  APPARATUS. 

are  thrust  into  the  soft  parts  around  the  teeth. 
Brushes  of  badger's  hair,  of  felt,  and  of  various  other 
substitutes,  have  been  recommended.  Most  of  these 
contrivances,  however,  are  lacking  in  the  essential 
resistance  and  elasticity  so  important  in  the  thorough 
dislodgement  of  foreign  matter.  The  bristle  brush  in 
which  the  bristles  are  not  too  closely  placed  together, 
thus  admitting  of  their  passage  between  the  teeth,  is 
the  most  practical  instrument.  Great  care  should  be 
taken  not  to  allow  the  bristles  to  spread,  and  the 
brush  should  be  discarded  before  it  is  soft  or  ragged 
from  long  use.  The  brush  should  not  be  too  broad, 
and  the  handle  should  be  bent  in  the  direction  of  the 
tuft  on  the  brush  so  as  to  admit  more  easily  the 
reaching  of  the  various  curved  surfaces  of  the  teeth. 
The  brushing  should  be  practised  after  each  meal 
and  before  going  to  bed,  and  once  daily  should  be  ac- 
companied by  the  use  of  a  tooth-powder  sufficiently 
coarse  to  produce  some  grinding  and  polishing  effect. 
A  powder  that  is  too  soft  or  too  fine  is  of  little  avail. 
Powdered  chalk  and  orris  root  are  common  bases  for 
tooth-powder.  Some  harmless  antiseptic,  such  as 
borax,  oil  of  wintergreen,  or  tincture  of  myrrh,  should 
be  incorporated  with  the  powder  to  help  destroy  any 
colonies  of  bacteria  that  may  be  reached.  Twice  each 
week  all  the  exposed  surfaces  of  the  teeth  should  be 
carefully  gone  over,  and,  with  the  assistance  of  the 
tooth-powder,  carefully  rubbed  with  a  narrow  chisel- 
like piece  of  a  w^ood  that  is  hard  and  fine-grained 
in  texture,  such  as  orange-wood,  so  as  to  smooth 
away  all  the  roughness  and  inequalities.  This  puts  a 
smooth  polish  on  the  teeth  and  renders  their  subse- 
quent cleansing  by  means  of  the  tooth-brush  a  com- 


IMPORTANCE    OF  THE    TEETH  JN  DIGESTION.     25 

paratively  simple  matter.  If  this  rule  were  applied 
in  the  care  of  children's  teeth,  the  work  of  the  dentists 
would  be  greatly  restricted.  Of  equal  importance  is 
the  daily  use  of  soft,  silk  twine,  known  as  dental 
floss.  It  should  be  drawn  between  the  teeth  firmly 
but  carefully,  so  as  to  remove  foreign  matter  that  can- 
not be  reached  in  other  ways.  It  is  important  not  to 
cut  or  irritate  the  gums  nor  to  loosen  their  attachments 
to  the  teeth.  A  little  experience  enables  one  to  ac- 
complish the  work  deftly  and  quickly.  In  the  neglect 
of  this  practice  the  teeth  can  hardly  be  said  to  have 
been  cleaned.  In  addition  to  these  methods,  the 
mouth  and  teeth  should  be  carefully  rinsed  every 
night  with  some  innocuous  antiseptic  solution.  Some 
of  the  most  harmless  antiseptics  are  powerful  germi- 
cides, and  should  be  employed  to  the  exclusion  of 
others  that  may  do  injury  to  the  general  health  of  the 
individual  as  well  as  to  the  teeth.  Tincture  of  orris, 
rose-water,  and  alcohol  in  equal  parts,  flavored  with  a 
drop  of  oil  of  bitter  almond,  make  a  very  agreeable 
mouth-wash,  and  it  may  be  rendered  more  actively 
antiseptic  by  the  addition  of  0.5  per  cent,  of  formalin. 
The  importance  of  the  teeth  in  digestion  is  not 
sufficiently  recognized.  Many  cases  of  chronic  indi- 
gestion arise  from  imperfect  mastication  due  to  faulty 
dentition.  In  all  such  cases  it  is  of  primary  impor- 
tance to  have  decayed  teeth  filled,  or  if  there  are  many 
missing  teeth  they  should  be  replaced  by  artificial 
ones.  Otherwise  medication  and  dietary  regulation 
may  be  of  little  avail. 


26        '  THE  DIGESTIVE  APPARATUS. 

HYGIENE  OF  THE  GASTRO=INTESTINAL  TRACT. 

The  Appetite. — When  there  is  bodily  inactivity  or 
mental  indolence,  as  compared  with  habitual  physical 
or  mental  exertion,  the  problems  of  nutrition  must 
differ  widely.  The  long  struggle  of  the  human  race 
to  find  at  all  seasons  sufficient  nourishment  to  satisfy 
the  demands  of  life  doubtless  led  to  the  building  up  of 
physiologic  laws  which  made  it  possible  for  the  or- 
ganism to  undergo  periods  of  starvation,  to  be  fol- 
lowed by  periods  of  repletion.  Thi^  history  of  feast 
and  famine  must  have  left  to  its  survivors  an  appe- 
tite that  urged  its  possessor  to  feats  requiring  the 
greatest  energy  of  body  and  mind  ;  conversely  great 
activity  and  great  expenditure  of  energy  should 
lead  normally  to  an  appetite  correspondingly  large. 

In  reviewing  the  history  of  organized  life,  it  will  be 
found  that  appetite  has  been  the  great  ruling  principle 
that  has  enabled  the  living  cell  to  cope  successfully 
with  the  destructive  agents  that  surrounded  it.  A 
good  appetite  still  reminds  one  of  the  most  necessary 
factors  in  our  survival,  and  we  instinctively  feel  that 
its  disappearance  or  its  unnatural  perversion  is  a  seri- 
ous warning  of  degeneracy  or  decay.  This  splendid 
instinct  so  necessary  for  our  existence  has  now  more 
than  ever  to  meet  with  sudden  modifications  resulting 
from  the  complexity  of  modern  life.  While  pri- 
marily responsible  for  the  discovery  of  innumerable 
aliments,  the  very  abundance  in  this  generation,  both 
in  quantity  and  variety,  is  embarrassing,  and  we  find 
the  results  of  unnecessary  and  artificial  stimulation 
in  the  unnatural  desires  for  food.  The  lack  of  at- 
tention as  to  the  appropriateness  of  food  subjects  not 
only  the  digestive  apparatus,  but  all  the  cells  of  the 


THE   EFFECT  OF   THE  MIND    ON  NUTRITION.      2/ 

individual  organism  to  distress  and  not  infrequently 
to  disease.  In  this  matter  the  problem  to  be  solved 
is,  first,  how  to  train  the  appetite  into  natural  and 
wholesouie  paths;  and,  second,  how  to  live  so  that  by 
means  of  proper  physical,  mental,  and  moral  activity 
there  may  be  successfully  oxidized  the  kind  and 
quantity  of  nutriment  required  in  normal  life,  and 
successfully  discharged  the  waste  products  that  re- 
sult from  the  oxidation.  It  is  unsafe  to  trust  the 
individual  to  the  guidance  of  the  appetite  alone, 
for  the  reason  that  this  instinct  was  built  up  for  a 
condition  of  existence  very  different  from  that  which 
enables  the  people  of  this  country  to  indulge  them- 
selves to-day.  Nevertheless,  the  appetite  is  a  more 
reliable  guide  than  speculation,  and  more  trustworthy 
than  a  certain  narrow  scientific  view  which  would 
select  foods  along  the  lines  of  nutritive  values  ascer- 
tained by  chemical  experiments.  Not  that  there 
should  be  neglect  of  knowledge  as  to  the  calories  of 
energy  that  may  be  developed  by  one  substance  as 
compared  with  another,  or  the  omission  of  some  things 
that  may  be  learned  by  rational  deduction;  but  it 
should  never  be  forgotten  that  in  instinct  there  is  a 
guide  that  has  been  accumulating  experience  for  un- 
known ages,  and  that  if  life  in  other  respects  is 
normal  this  appetite  is  likely  to  lead  very  nearly  in 
the  right  direction. 

The  Effect  of  the  Mind  on  Nutrition. — These  gen- 
eralities include  many  specific  facts  that  will  bear 
amplification.  In  the  consideration  of  the  efiect  of 
the  mental  and  moral  state  upon  the  problems  of 
nutrition  there  is  much  food  for  thought.  It  is  no 
idle  phrase  to  say   that  a  contented  mind,    a  willing 


28       '  THE  DIGESTIVE  APPARATUS. 

disposition,  and  a  joyous  nature  give  rise  to  good 
digestion.  It  is  a  truth  of  such  importance  that  no 
physician  can  wholly  succeed  in  relieving  derange- 
ments of  digestion  unless  he  takes  this  matter  into 
consideration  ;  in  other  words,  remorse,  worry,  over- 
responsibility,  petulance,  envy,  jealousy,  and  other 
undesirable  mental  states  give  rise  to  such  disturb- 
ances, both  in  primary  nutrition  and  cellular  met- 
abolism, that  good  health  is  not  to  be  obtained.  This 
explains  the  fact  that  a  change  of  scene,  a  long  vaca- 
tion, and  new  associations  will  sometimes  improve 
the  digestion  and  restore  health  generally  when  care- 
ful dieting  and  other  measures  have  failed  to  bring 
relief.  Unenviable  mental  characteristics  may  be- 
come prominent  partly  as  the  result  of  brain  irritation 
that  arises  in  many  unsuspected  ways.  Such  dis- 
turbance of  the  nervous  system  deranges  the  appetite, 
the  digestion,  and  nutrition  in  general,  as  well  as  the 
mentality. 

The  Effect  of  Eye-strain  on  Nutrition. — One  of 
the  most  important  of  these  sources  of  irritation  is  the 
continual  use  of  the  eyes  in  all  manner  of  fine  work, 
often  in  imperfect  or  wrongly  directed  light.  In  the 
modern  system  of  education,  in  which  children  from 
the  kindergarten  upward  are  required  to  use  the  eyes 
closely  upon  small  objects,  in  association  with  the 
concentration  of  the  mind,  this  evil  is  found  in  an  ag- 
gravated form.  As  this  sacrifice  of  the  ocular  ap- 
paratus seems  demanded  by  the  requirements  of  edu- 
cation and  culture,  the  nervous  system  has  to  undergo 
the  strain  as  best  it  may.  It  has  long  been  recog- 
nized that  there  result  headache  and  various  expres- 
sions   of    nervousness,    but  that    the    appetite    and 


THE   EFFECT  OF  EYE-STRAIN  ON  NUTRITION.     29 

digestion  are  also  made  to  suffer  are  facts  that  are 
too  little  recognized.  Whoever  carefully  looks  into 
this  matter  will  find  really  that  nutrition  first  shows 
the  result  of  nerve-strain,  no  matter  from  what 
source  arising  ;  and,  as  a  rule,  some  peculiarity  of  the 
primary  digestion  gives  the  earliest  intimation  of  the 
trouble.  For  instance,  there  may  develop  a  distaste 
for  certain  substances  in  the  dietary  ;  the  appetite 
may  become  capricious  or  perverted.  Again,  a  dis- 
turbance in  motion  will  arise,  and  the  stomach  may 
contract  in  a  spasmodic,  tremulous,  or  irregular  way, 
while  the  individual  is  conscious  of  disagreeable  and 
sometimes  alarming  sensations,  accompanied  with 
eructations  of  gas  or  fluid  from  the  stomach.  Or  the 
gastric  juice  may  be  secreted  irregularly,  and  in  many 
instances  a  long  chain  of  dyspeptic  symptoms  appear 
without  any  real  disease  of  the  stomach,  but  merely 
a  disturbance  of  the  nervous  system  occasioned  by 
improper  habits  of  life.  In  a  certain  sense  the  stom- 
ach is  acting  in  the  role  of  monitor  ;  but  if  we  are 
sufficiently  wise  it  may  often  be  regarded  as  that  of 
the  kind  mentor.  This  most  common  experience 
may  be  avoided  sometimes  by  removing  the  strain  to 
the  nervous  system,  and  again  by  strengthening  it  by 
exercise,  bathing,  recreation,  and  more  hours  for 
sleep  and  repose.  Eye-strain  may  be  lessened  or  ob- 
viated by  the  wearing  of  spectacles  that  are  made  ac- 
curately and  adjusted  precisely;  or  by  attending  to  the 
direction  in  which  light  enters  the  room,  or  perhaps 
by  prohibiting  the  use  of  books  printed  with  small 
or  illegible  type.  Observance  of  these  precautions 
may  render  it  unnecessary  for  the  individual  to  give 
special  attention  to  his  diet  ;  but  it  is  the  usual  cus- 


30  THE   DIGESTIVE   APPARATUS. 

torn  at  first  for  the  stomach  to  be  considered  the 
source  of  trouble.  As  the  disagreeable  digestive  ex- 
periences are  attributed  to  the  stomach,  the  fault  is 
commonly  supposed  to  lie  in  the  character  of  the 
food,  and  wiseacres  take  the  responsibility  of  advis- 
ing the  withdrawal  of  sugar,  fats,  or  meats,  and  the 
abundant  taking  of  oatmeal,  grits,  and  beef-tea,  a 
dietary  most  likely  to  undermine  resisting  power  and 
in  the  end  do  infinite  harm.  For  similar  relief  re- 
sort is  sometimes  had  to  a  milk  diet  or  to  abstinence 
from  food,  because  it  is  found  that  the  stomach  is 
more  comfortable  when  it  has  little  to  do.  But  this 
erroneous  course  will  ultimately  fail  ;  it  is  wiser,  when 
possible,  to  remove  the  cause  of  the  difficulty. 
When  it  is  impracticable  to  remove  the  source  of 
worry  it  becomes  necessary  to  modify  the  diet,  and  it 
is  a  compromise  of  this  sort  that  unfortunately  we 
must  sometimes  make. 

Regulation  of  Meals. — When  required  to  adapt 
the  diet  to  a  tired  nervous  system  and  an  irritable 
stomach  it  must  be  so  managed  that  the  most  hearty 
meal  should  be  taken  at  a  time  when  it  is  possible 
for  the  individual  to  enjoy  the  greatest  physical  and 
mental  composure,  and  there  should  not  be  demanded 
too  much  of  the  digestive  organs  when  it  is  known 
that  unusual  taxation  of  the  nervous  system  has  been 
experienced.  It  is  not  generally  wise  in  such  cases 
to  take  a  hearty  breakfast  before  functional  activity 
is  sufficiently  aroused  ;  nor  is  it  well  to  allow  the 
chief  meal  at  midday,  when  the  energy  is  likely  to  be 
taxed  by  work  or  study.  It  is  better  to  wait  until 
late  in  the  afternoon,  when,  after  a  little  rest,  the 
chief  meal  should  be  taken — and  taken  slowly,  com- 


REGULATION  OF  MEALS.  3  I 

posedly,  and  cheerrully.  T'ollowin*,^  tliis  tlierc  slioiikl 
be  spent  a  few  hours  in  quiet  enjoyment  before  ;<oin<^ 
to  bed. 

This  rule  will  seem  like  an  absurdity  to  many 
who  insist  that  the  late  dinner  is  in  itself  the  sure 
forerunner  of  a  bad  night.  This  is  usually  true 
only  when  the  midday  meal  has  been  too  hearty. 
A  delicate  digestion  may  be  overtaxed  by  requiring 
the  stomach  to  muster  all  its  forces  too  frequently  in 
a  given  time.  It  is  better  economy  to  accept  from 
the  organism  a  moderate  display  of  energy  in  the 
morning,  and  very  slight  at  midday  ;  but  at  evening, 
when  the  tissues  demand  food  and  when  the  physiologic 
appetite  has  appeared,  it  may  be  expected  that  the  di- 
gestion will  perform  its  greatest  work  unincumbered 
by  worries — muscular  and  mental  activities  that  are 
likely  to  draw  the  blood  away  from  the  organs  of  di- 
gestion and  to  dissipate  vital  energy  in  too  many 
ways  at  one  time.  If  this  principle  is  true,  there  is 
HO  reason  why  it  may  not  apply  to  children  as  well 
as  to  adults.  Of  course,  this  need  not  be  construed 
too  literally  in  cases  of  sturdy  and  hungry  little  folks, 
who  are  always  ready  to  eat.  The  application  of  the 
rule  should  be  in  proportion  to  the  delicacy  of  the 
child  ;  but  it  must  be  remembered  that  the  food  for 
the  child  should  be  that  which  is  quickly  disposed  of, 
and  therefore  a  greater  frequency  of  meals  is  usually 
permissible.  In  fact,  it  is  not  safe  to  use  an  invari- 
able law  as  to  the  frequency  of  meals  in  persons  of 
any  age,  but  regularity  should  be  insisted  upon.  Con- 
vention is  too  often  the  arbiter  in  the  matter,  and 
the  hmirs  for  eating  are  appointed  without  reasonable 
regard  to  physiologic  requirements.      Nevertheless, 


32  THE  DIGESTIVE  APPARATUS. 

the  rule  given  above  may  be  taken  as  an  illustration 
that  is  applicable  to  the  majority  of  mankind.  It  does 
not  mean  that  the  average  man  has  a  weak  digestion, 
but  it  means  that  he  is  overtaxed  in  a  general  way,  and 
that  if  he  does  not  devote  some  thought  to  the  char- 
acter of  his  meals  and  to  the  hour  for  his  repasts,  then 
he  is  likely  to  develop,  first,  consciousness  of  the  act 
of  digestion,  and,  later,  distress  during  the  process. 

Regulation  of  the  Diet. — It  is  frequently  asked 
what  should  be  the  character  of  the  food  taken.  The 
answer  must  at  first  be  as  general  as  the  question  ; 
and  it  may  be  said  that  the  digestion  may  be  taxed 
either  in  the  quantity  or  the  quality  of  food,  and  in 
direct  ratio  with  the  resisting  power  and  vital  energy 
of  the  individual.  The  climate  and  occupation  must 
also  be  considered.  A  stalwart  wood-chopper  requires 
in  the  winter  large  meals  rich  in  fats  and  carbohy- 
drates, which,  in  the  process  of  oxidation,  produce 
relatively  a  large  amount  of  heat,  and  albumins  that 
more  directly  nourish  the  muscles  and  nerves.  With 
such  a  worker,  so  long  as  there  is  sufficient  nutritive 
value  in  the  food,  great  attention  need  not  be  paid  to 
its  variety,  nor  even  to  its  digestibility.  For  instance, 
certain  woodsmen  crave  a  very  resisting  form  of 
pastry  because  it  "stays  by"  and  does  not  too 
quickly  leave  the  stomach  empty.  For  such  per- 
sons the  hastily  prepared  oatmeal-porridge  is  suit- 
able, because  it  is  slow  to  digest. 

For  the  sedentary  and  indolent  person  the  supply 
of  food  should  be  small  and  digestible.  For  the  sed- 
entary brain-worker  the  amount  taken  should  be 
increased  in  proportion  to  his  mental  activity,  knd  it 
should  be  easily  digestible  and  very  nutritious.     In  a 


KEGULATION  OF   THE  DIET.  33 

cold  climate,  as  is  generally  known,  large  amounts  of 
fats  are  required,  while  in  hot  climates  the  carbo- 
liydrates  and  fruits  seem  to  be  demanded  by  the  or- 
ganism. 

For  the  ordinary  business  or  professional  man, 
or  the  student,  a  breakfast  may  be  advised  to  con- 
sist of  one  or  two  soft-boiled  eggs  or  an  omelet,  a 
piece  of  bacon  or  fish,  a  roll  or  some  toast,  and  one 
cup  of  coffee.  Oatmeal-pudding  is  unsuitable,  be- 
cause it  is  rarely  well  mixed  with  saliva,  but  is  hur- 
riedly bolted,  deglutition  being  facilitated  by  the 
covering  of  cream.  The  same  may  be  said  of  other 
"cereals,"  except  those  that  are  partially  dextrinized 
by  previous  cooking  in  the  process  of  manufacture. 
Early  in  the  morning  at  least  a  glassful  of  pure  water, 
neither  iced  nor  hot,  should  be  taken. 

If  the  breakfast  hour  is  at  eight,  the  luncheon  hour 
should  be  at  one.  Milk  is  an  excellent  aliment  for  this 
meal.  It  disagrees  with  some,  but  this  is  usually  be- 
cause other  foods  are  taken  with  it.  Milk  is  not  to  be 
regarded  as  a  drink,  but  as  a  food.  It  is  best  taken 
alone,  but  it  generally  agrees  better  if  a  certain  amount 
of  starchy  food  is  taken  at  the  same  time,  although  the 
latter  should  be  carefully  masticated  and  insalivated, 
and  should  neither  be 'saturated  with  milk  nor  washed 
down  by  it.  Milk  should  be  drank  and  bread  eaten 
slowly.  The  object  of  this  is  to  take  advantage  of 
the  action  of  the  saliva  in  converting  starch  into 
maltose.  For  those  who  dislike  milk,  or  with  whom 
it  does  not  agree,  the  luncheon  may  consist  of  broth 
or  light  soup,  bread  and  butter,  a  few  oysters,  sweet- 
bread or  stewed  lobster,  and  perhaps  a  little  fari- 
naceous pudding  like  corn-starch,  thoroughly  pre- 
3 


34  THE  DIGESTIVE  APPARATUS. 

pared  rice,  or  tapioca.  Of  such  a  luncheon  fruit  may 
form  a  part,  or  fruit  may  be  taken  before  breakfast, 
and  rarely  after  dinner.  With  such  an  arrangement, 
dinner  should  be  taken  at  six  or  thereabouts.  This 
meal  should  be  as  much  as  possible  served  slowly 
in  courses.  The  conventional  arrangement  of  the 
courses  at  dinner  is  a  desirable  one,  and  is  appar- 
ently the  result  of  the  experience  of  ages.  The  pre- 
liminary course  of  a  good  soup  that  is  not  too  rich, 
to  be  followed  by  fish,  then  a  joint  or  roast,  with  one 
or  two  vegetables,  a  small  salad,  bread,  and  some 
simple  dessert  constitute  a  typical  dinner,  and  in 
amount  should  be  sufficient  to  make  up  for  the  some- 
what scanty  meals  that  preceded  it. 

The  digestion  is  usually  taxed  in  proportion  to  the 
variety  of  the  foods  taken;  therefore,  when  the  stomach 
reacts  unfavorably  to  an  extended  meal,  food  should 
be  limited — first  in  variety,  and  second  in  quantity. 
The  precise  amount  to  be  taken  during  all  these  meals 
is  a  matter  that  must  depend  upon  individual  require- 
ments. As  a  rule,  more  food  is  taken  than  neces- 
sary; but  there  is  a  large  class  of  nervous  people  who 
eat  regularly,  but  rarely  take  a  sufficient  amount  of 
really  nourishing  foods  to  replace  that  which  is  lost 
by  waste. 

The  following  table  is  given  by  Parkes  as  showing 
the  amount  of  food  required  by  a  healthy  adult  in 
24  hours  (see  page  383): 

In  laborious  occupation.  At  rest. 

Nitrogenous  substances — ,f.^.  flesh    .    .     6.0  to     7.0  oz.  av.  2.5  oz.  av. 

Fats 3-5  "     4-5       ''  i-o      " 

Carbohydrates l6.o  "    18.0       "  12. o      " 

Salts I  2  "     1.5       "  0.5      " 

26.7  to  31.0  oz.  av.  16.0  oz.  av. 


PROl'KR    COOKhXG.  35 

To  this  should  be  added  from  fifty  to  eighty  ounces 
of  fluid. 

In  the  arrangement  of  meals  above  described  the 
requirements  of  the  average  brain-worker  have  been 
in  mind.  In  some  cases  a  heartier  breakfast  will  be 
demanded,  and  with  others  a  certain  amount  of  lassi- 
tude and  depression  may  occur  late  in  the  afternoon 
when  only  a  light  luncheon  has  been  taken.  If  the 
latter  complaint  is  made,  relief  may  be  had  by  allow- 
ing a  cup  of  tea  and  a  cracker  to  be  taken  at  four 
o'clock.  Drank  at  this  time,  tea  rarely  disturbs  sleep, 
and  it  is  not  likely  to  blunt  the  appetite  for  dinner. 
Some  individuals  have  naturally  a  rapid  digestion, 
and  a  sense  of  hunger  is  experienced  toward  bedtime. 
In  such  an  event  it  is  best  that  a  little  simple  food  be 
taken.  Only  those  who  have  vigorous  constitutions 
can  indulge  at  night  in  "lobster  a  la  Newburgh," 
rarebit,  and  the  various  other  savory  and  rich  prepara- 
tions that  the  use  of  the  chafing-dish  has  made  popu- 
lar. This  is  not  an  argument  against  eating  before 
going  to  bed,  but  merely  an  instance  of  the  impru- 
dence of  taking  food  unsuited  to  the  individual  or  to 
the  occasion.  It  must  not  be  supposed  that  the 
dietary  cannot  be  varied,  for  there  is  no  doubt  that 
monotony  in  daily  living  is  bad  hygiene. 

Proper  Cooking. — -Many  articles  of  diet  that  are 
considered  unwholesome  are  usually  so  merely  because 
they  are  badly  prepared.  Hardly  too  much  can  be 
said  in  favor  of  scientific  cooking,  and  that  most 
important  article  of  diet,  bread,  is  most  often 
open  to  criticism.  Really  well-baked,  sweet,  crisp, 
"  nutty  "  bread  is  regularly  found  only  in  exceptional 
households.     Indeed,   many   people   do   not  seem  to 


36    ^  THE  DIGESTIVE  APPARATUS. 

know  what  ' '  good  bread ' '  means.  Much  of  the 
tirade  against  potatoes  is  unjust,  and  results  from  igno- 
rance in  their  preparation  or  the  prejudice  of  certain 
writers.  A  great  variety  of  green  vegetables  that  are 
not  only  palatable  but  fairly  nutritious,  and  some  of 
the  constituents  of  which  are  necessary  because  they 
contain  acids,  salts,  and  extractive  matters  required 
by  the  economy,  are  easily  enough  digested  when  they 
are  well  prepared.  Aside  from  their  nutritive  value, 
they  are  useful  in  making  more  bulky  the  contents  of 
the  alimentary  canal,  thus  favoring  the  action  of 
the  stomach  and  intestines,  whereby  constipation  is 
avoided  and  a  healthy  state  of  the  intestinal  mucous 
membrane  is  favored. 

Fruits. — It  is  rarely  necessary  to  urge  Americans  to 
eat  fruit;  they  too  often  err  in  taking  too  much.  It 
is  not  uncommon  in  this  country  for  people  to  eat 
fruit  at  any  time  during  the  day  or  evening.  The 
benefits  from  eating  fruits  are  undoubted;  they  act 
upon  the  digestive  organs  somewhat  like  the  green 
vegetables,  but  they  have  other  advantages  from  the 
acids  contained,  and  also  because  they  appeal  to  the 
esthetic  sense.  The  eating  of  fruit  before  breakfast 
is  unobjectionable  in  most  instances.  Fruit  may  also 
properly  form  a  part  of  the  luncheon  and  dessert,  but 
it  should  not  be  eaten  between  meals.  The  harm  in 
eating  fruit  may  lie  in  its  excessive  use,  or  in  eating 
that  which  is  unsound  or  unripe. 

Coffee,  tea,  and  cocoa  have  their  place  in  normal 
diet;  and  while  they  occasionally  are  the  source  of 
much  disturbance,  it  is  generally  true  because  of  over- 
indulgence in  them.  As  a  rule,  coffee  and  tea  are 
taken  in  excess,  and,  on  the  whole,  do  more  harm 


FATS  AND    OILS.  37 

than  good.  The  plea  is  made  for  the  temperate  use 
of  these  substances  that  have  come  to  be  ahnost 
necessities  of  the  human  race.  After  the  morning 
bath  a  small  cup  of  coffee,  gently  stimulating  the 
circulation  and  the  motor  function  of  the  alimentary 
tract,  and  apparently  making  more  available  the 
energy  accumulated  during  the  night's  rest,  generally 
accomplishes  good.  The  use  of  tea  in  the  afternoon 
has  been  pointed  out.  Both  coffee  and  tea,  particu- 
larly the  latter,  antagonize  the  action  of  the  saliva 
upon  starch,  and,  therefore,  taken  in  excess  may  retard 
digestion.  There  will  ensue  little  trouble  if  bread  is 
sufficiently  well  masticated  and  if  no  drink  be  taken 
while  eating.  The  saliva  passing  with  the  food  into 
the  stomach  stimulates  the  secretion  of  that  organ, 
and  therefore  indirectly  assists  in  the  digestion  of 
the  albumins.  This  is  another  reason  why  careful 
habits  in  eating  should  be  inculcated  early  in  life. 

Sugar  contains  much  stored-up  energy,  and  is  a 
useful  article  of  diet;  but  if  taken  early  in  the  meal, 
it  lessens  the  appetite  and  embarrasses  digestion. 

The  action  of  condiments  is  quite  varied.  Most 
of  them  appeal  to  the  sense  of  taste,  and  act  as  local 
salivary  and  gastric  stimulants.  The  high  seasoning 
of  food  not  only  depresses  the  sense  of  taste  for  simpler 
foods,  but  also  exercises  a  harmful  influence  in  irri- 
tating the  gastric  and  intestinal  mucous  membranes 
and  the  liver. 

Fats  and  oils  should  be  included  in  every  rational 
dietary.  Even  in  warm  climates  these  substances 
have  always  formed  an  important  item  in  the  foods 
that  are  selected  by  choice.  It  is  difficult  to  explain 
the   fact  that   they  are   disliked   by  some   children, 


38  THE  DIGESTIVE  APPARATUS. 

although  the  health  may  be  failing  for  the  want  of 
them.  In  such  cases  evident  improvement  is  ob- 
served when  fats  are  prescribed  by  the  physician. 
Fats  should  not  be  taken  before  or  early  in  the  meal, 
for  the  reason  that  they  are  supposed  to  protect  the 
mucous  membrane  of  the  stomach  from  its  normal 
stimulation  by  the  other  foods,  and  thus  tend  to  lessen 
the  secretion  and  motion  of  that  organ.  If  fats  are 
taken  late  in  the  meal  or  following  it,  they  do  not  dis- 
turb digestion  unless  fermentation  occurs.  While  in 
the  stomach  the  delicate  envelopes  of  the  fat-cells  are 
broken,  when  they  pass  with  the  chyme  into  the  in- 
testine and  are  -absorbed  by  the  lacteals  in  the  villi. 
Intestinal  digestion  of  fats  seems  to  be  merely  that  of 
the  splitting  up  of  the  fat-cells,  a  process  of  emulsifi- 
cation  that  is  for  the  most  part  accomplished  by  the 
action  of  the  pancreatic  juice,  assisted  by  the  secre- 
tions of  the  liver  and  duodenum.  Quantities  of  minute 
particles  of  fat  thus  subdivided  are  to  be  found  in  the 
lacteals  during  intestinal  digestion,  and  they  subse- 
quently appear  in  the  blood,  from  which  the  tissue- 
cells  readily  appropriate  them.  It  will  thus  be  seen 
that  the  assimilation  of  fats  is  a  simpler  process  than 
that  attending  the  albuminoids,  starches,  and  sugars; 
and  to  suppose  that  fats  are  unwholesome  is  an  erro- 
neous conclusion,  probably  based  upon  the  fact  that 
when  incorporated  with  starches  and  sugar  in  the  form 
of  pastries,  etc.,  they  are  likely  to  disturb  digestion. 
This  is  true  for  the  reason  that  the  starch-cells  are  pro- 
tected by  the  fats  from  the  action  of  the  saliva  in  the 
mouth  and  stomach  and  from  the.  action  of  the  pan- 
creatic juice  in  the  intestine;  and  for  the  further 
reason  that  the  fats  are  often   superheated  in  cook- 


DRINKING    WATEK.  39 

ing,  thus  giving"  rise  to  indigestible  and  irritating 
fatty  acids. 

The  salts  conii)ose  an  important  part  of  tlie  dietj 
and  occur  as  various  combinations  of  sodium,  potas- 
sium, lime,  magnesium,  and  ammonium.  Of  these, 
tlie  most  important  is  sodium  chlorid,  or  common 
salt,  which  makes  up  5.5  +  parts  in  every  1000  parts 
of  the  plasma  of  the  blood,  and  occurs  everywhere  in 
the  body  except  in  the  enamel.  A  sufficient  amount 
is  not  derived  from  unseasoned  foods,  and  therefore 
the  use  of  salt  as  a  condiment  is  universal.  Some  of 
its  derivatives,  of  which  hydrochloric  acid  is  the  chief, 
form  a  most  important  constituent  of  the  gastric  juice; 
and  it  seems  reasonable  that  salt  should  be  taken  in 
connection  with  the  albuminoids,  with  which  the  gas- 
tric juice  has  most  to  do  in  the  process  of  digestion. 
Salt  may  be  taken  in  excess  when  salted  meats  form 
the  chief  aliment  or  when  an  unnatural  habit  of  eat- 
ing salt  is  acquired.  But  if  one  is  deprived  of  salt 
there  is  not  only  a  disturbance  in  the  cellular  nutri- 
tion, but  also  a  depreciation  in  the  gastric  juice. 

Drinking  Water. — The  question  of  drinking  water 
is  one  that  requires  some  consideration.  As  has  been 
stated,  about  eighty  ounces  of  fluid  should  be  taken 
daily.  This  .includes  that  which  is  taken  in  combi- 
nation with  solid  foods.  Most  people  leading  sedentary 
lives  take  too  little  water,  and  also  err  in  taking  it  for 
the  most  part  when  eating.  A  certain  amount  of 
water  always  should  form  a  part  of  every  meal,  and 
particularly  is  it  necessary  in  those  who  have  very  ac- 
tive digestion.  It  assists  the  escape  from  the  stomach 
of  those  substances  made  soluble  by  the  action  of  the 
gastric  juice  and  the  churning  eflfect  of  the  stomach, 


40     .  THE  DIGESTIVE   APPARATUS. 

and  will  sometimes  make  digestion  comfortable  when 
it  otherwise  would  be  attended  with  distress.  But 
while  it  is  allowable  for  water  to  be  taken  with  meals, 
it  again  should  be  repeated  that  the  food  should  not  be 
washed  down.  Such  a  practice  not  only  interferes  with 
starch  digestion,  but  it  also  enables  the  individual  to 
swallow  morsels  of  food  altogether  too  large  and  re- 
sisting for  the  stomach  to  manage  comfortably.  The 
proper  time  for  taking  the  bulk  of  the  fluid  is  between 
meals,  particularly  early  in  the  morning  and  late  at 
night.  It  is  a  fact  well  known  to  physicians  that 
women  especially  drink  too  little  water ;  the  habit 
probably  results  from  the  inconvenience  attending  the 
taking  of  the  proper  amount.  While  a  person  may 
be  saved  some  embarrassment  by  this  kind  of  denial, 
positive  harm  usually  results  from  the  continuance  of 
the  practice.  The  American  habit  of  drinking  ice- 
water  has  been  much  censured.  It  is  unnatural,  and 
in  some  instances  harm  may  be  traced  directly  to  it. 
In  many  no  injurious  effect  appears  to  follow  its 
use.  This  must  be  said  in  its  favor,  that  those  who 
enjoy  cold  drinks  are  likely  to  take  sufficient  water, 
which  is  not  true  of  the  ordinary  individual. 

Harm  comes  from  the  practice  of  drinking  hot 
water  in  the  false  belief  that  it  prevents  or  cures 
dyspepsia.  Doubtless  hot  water  has  its  place,  and  it 
is  to  be  recommended  rather  as  a  remedy  than  as  a 
daily  usage. 

Alcoholic  Beverages. — In  general  it  may  be  said 
that  alcohol  is  unnecessary ;  and,  aside  from  the  vi- 
cious results  of  inebriety,  it  sometimes  is  capable  of 
producing  disturbances  of  digestion.  This  is  particu- 
larly true  in  those  unaccustomed  to  its  use,  and  is  truer 


STIMULANTS.  4I 

of  beer  and  wines  than  of  the  distilled  liquors,  except 
when  they  are  used  too  freely.  With  the  continued 
use  of  alcohol  in  any  form  it  is  possible  so  to  disturb 
the  nervous  system  that  nausea,  loss  of  appetite,  and 
other  functional  disturbances  arise;  and  if  the  practice 
is  still  further  continued  congestion  and  catarrh  of  the 
stomach  and  irritation  of  the  liver  may  be  expected. 
These  facts  are,  of  course,  universally  accepted;  but 
the  question  is  how  much  may  digestion  be  harmed 
from  the  taking  of  a  small  amount  of  wine  or  spirit  as 
a  part  of  an  occasional  feast  or  as  a  regular  accompa- 
niment of  dinner.  While  it  is  a  fact  that  wines  and 
beers  rich  in  extractive  matters  interfere  with  gas- 
tric digestion,  it  must  be  admitted  that  unpleasant 
effects  are  not  usually  experienced  in  temperate 
people,  particularly  when  they  are  active  in  mind 
and  body.  Certain  individuals  are  always  the  worse 
from  even  the  temperate  use  of  alcohol,  tobacco,  tea, 
or  coffee;  and  such  individuals  should  also  abandon 
chocolate  and  cocoa.  These  persons  are  exceptional, 
however,  and  in  the  case  of  the  ordinary  man,  lead- 
ing an  active  life,  a  moderate  amount  of  alcohol  may 
be  taken  without  harm.  Unfortunately,  moderation 
is  not  satisfactory,  and  deplorable  results  may  arise 
that  are  apparently  traceable  to  the  gradually  increas- 
ing use  of  alcohol. 

Other  Stimulants. — It  is  held  by  certain  authors 
that  stimulants  of  all  kinds  should  be  avoided,  which 
would  put  the  ban  of  exclusion  upon  condiments, 
spices,  hot  foods,  ice,  and  carbonated  drinks,  as  well  as 
upon  tea,  coffee,  cocoa,  and  alcohol.  But  this  posi- 
tion is  not  logical,  for  it  can  be  shown  that  the  diges- 
tive apparatus  is  stimulated  on  the  one  hand  and  de- 


42      >  THE  DIGESTIVE  APPARATUS. 

pressed  on  the  other  by  equally  potent  factors  that 
cannot  be  excluded;  for  instance,  by  constantly  occur- 
ring emotional  stales  as  well  as  by  recreation,  exertion, 
and  fatigue.  The  latter  group  will  be  considered  as 
merely  physiologic  influences,  and  therefore  not  open 
to  criticism;  but  this  conclusion  is  not  altogether 
true.  Certain  mental  states  result  in  interference 
with  digestion  to  such  an  extent  that  the  appetite 
may  be  lost,  nausea  induced,  the  gastric  secretion 
interrupted,  and  the  movements  of  the  stomach  and 
intestine  depressed,  or  irregular  and  spasmodic 
movements  induced  which  lead  to  the  upward  dis- 
charge of  gas  from  the  stomach  and  perhaps  regurgi- 
tation or  vomiting  of  the  undigested  food;  or  there 
may  be  developed  such  severe  contraction  of  the  gas- 
tric muscles  that  pain  is  induced.  The  same  causes 
very  frequently  induce  gastric  distress  and  occasional 
neuralgia.  On  the  other  hand,  in  tempting  displays, 
agreeable  zests,  and  appetizing  odors,  we  have  in- 
stances of  stimulants  that  as  often  lead  to  excess  in 
eating  as  they  do  to  increased  activity  in  digestion. 
A  curious  phenomenon  is  the  overdistention  of  the 
stomach  and  intestine  with  gas  which  apparently  does 
not  arise  from  fermentation,  but  appears  to  be  abnor- 
mally secreted  in  the  stomach  and  bowels.  Under  such 
conditions  a  gentle  stimulant  will  enable  the  diges- 
tive organs  to  regain  their  equilibrium,  after  which  a 
small  amount  of  fluid  food  might  be  easily  managed. 
These  are  the  cases  for  a  cup  of  tea  or  coffee,  or  a  pos- 
set of  aromatic  herbs,  and  those  who  have  no  moral 
scruples  against  its  use  may  be  quickly  relieved  by  a 
thimbleful  of  brandy. 

Eating  after  Bathing. — A  similar  state  of  depres- 


EATING  AFTER   EXERCISE.  43 

sion  of  the  digestive  organs  may  result  from  a  too  pro- 
longed bath  ;  and  the  popular  opinion  that  it  is  un- 
safe to  eat  after  bathing  is  based  upon  the  fact  that 
functional  energy  is  for  the  time  being  apparently 
diminished,  and  in  some  people  digestion  is  thereby 
interrupted.  This  fact  does  not  apply  to  all  alike, 
but  it  is  true  with  sufficient  frequency  to  give  rise  to 
the  popular  belief. 

Eating  after  Exercise, — Physical  exertion  is  more 
likely  to  disturb  digestion  than  bathing.  Its  effect 
upon  the  digestion  is  similar  to  that  produced  by 
mental  fatigue.  Singularly  enough,  this  fact  has  not 
been  universally  recognized  ;  and  it  is  common  for 
people  who  are  physically  exhausted  from  tennis- 
playing,  bicycling,  and  other  violent  exercises  to  in- 
dulge themselves  in  a  hearty  repast  without  having 
previously  rested.  Most  people  understand  that  it  is 
imsafe  to  undergo  vigorous  exercise  directly  after  a 
meal  ;  but  they  do  not  realize  the  mistake  of  eating 
heartily  when  too  tired.  These  truths  apply  more 
to  those  who  are  untrained  and  unaccustomed  to 
physical  strain  ;  but  athletes  have  discovered  that  it 
is  not  wise  to  eat  heartily  when  about  to  engage  in 
great  exertion.  Flint  found  that  during  a  period  in 
which  the  pedestrian  Weston  walked  a  total  of  317 
miles  in  5  days,  he  consumed  on  an  average  about 
83  grammes  of  proteids  daily.  Yet  in  the  diet  of  an 
ordinary  farmer  or  mechanic  in  this  country-  about 
100  grammes  of  proteids  are  taken  during  24  hours. 
Of  course,  other  forms  of  food  besides  proteids  are 
taken,  and  much  energy  is  derived  from  the  combus- 
tion of  the  fats  and  carbohydrates.  As  a  rule,  a 
well-trained  man  who  is  carrying  on  for  a  prolonged 


44 


THE  DIGESTIVE  APPARATUS. 


period  unusual  physical  effort  is  able  to  eat  and  di- 
gest more  food  than  the  ordinary  man.  The  dispro- 
portion between  the  nutriment  taken  and  the  energy 
expended  may  be  approximately  ascertained  by  noting 
the  change  in  the  weight  of  the  body.  A.  P.  Bryant 
states  that  Sandow's  daily  diet  contains  244  grammes 
of  proteids,  which  supplied  4460  calories  of  energy. 
Under  great  strain  more  proteid  is  required  than 
under  conditions  of  normal   exercises  ;  but  when  the 

strain  is  to  be  short  and 
severe  it  is  wise  to  re- 
trench at  the  table  lest 
there  should  succeed  re- 
bellion in  the  stomach. 

Influence  of  Carriage 
and  Dress  on  Diges- 
tion.— Abnormal  condi- 
tions of  the  liver  are  for 
the  most  part  secondary 
to  disorders  of  the  stom- 
ach and  intestines,  and  in 
cases  in  which  there  is  de- 
rangement of  the  prima 
vise  it  is  usually  safe  to 
conclude  that  the  liver 
is  also  out  of  condition. 
One  of  the  most  com- 
mon causes  of  sluggish- 
ness in  hepatic  circula- 
tion and  secretion,  as 
well  as  of  the  disturb- 
ances of  the  intestines  and  other  portions  of  the 
digestive  apparatus,  may  be  attributed  to  faulty  car- 


FlG.  7. — Showing  constriction  of 
the  abdomen  and,  necessarily,  the 
displacement  of  the  abdominal  vis- 
cera, produced  by  an  improper 
corset. 


CARRIAGE  AND  DRESS  INEI.UENCING  DIGEST/ON.   45 

riage  of  the  body  and  relaxation  of  the  abdominal 
muscles,  lessening  of  the  abdominal  type  of  respira- 
tion, and  consequently  the  loss  of  diaphragmatic  mo- 
tion. All  of  these  conditions  are  very  much  aggra- 
vated, and  some  of  them  are  directly  induced,  by  the 
improper  dress  almost  universally  adopted  by  women, 
and  to  some  extent  by  children.  In  illustration  may 
be  instanced  a  woman  who  is  said  to  dress  loosely. 
With  her  corset  removed  she  is  found  to  measure 
twenty-seven  inches  around  the  waist,  but  as  ordi- 
narily dressed  she  measures  twenty-one  inches  around 
the  waist  outside  the  garments  (Fig.  7). 

For  the  correct  performance  of  function  on  the 
part  of  the  stomach,  liver,  and  intestines  it  is  neces- 
sary that  free  and  properly  related  movements  of 
these  organs  should  take  place.  Such  movements 
are  impossible  in  the  large  majority  of  women.  The 
defects  are  so  common,  and  the  deformities  of  the 
body  necessarily  associated  with  them  begin  so  early 
in  life,  that  they  are  largely  overlooked,  and  are 
argued  to  be  natural  and  beautiful  by  the  mass  of 
womankind.  A  certain  amount  of  intra-abdominal 
pressure  is  necessary  if  the  viscera  of  that  region  are 
to  be  held  in  their  proper  places  and  proper  relations. 
This  is  possible  only  when  the  body  is  erect  in  sit- 
ting and  standing,  when  the  chest  is  kept  habitually 
raised  to  its  normal  position,  and  when  the  abdom- 
inal muscles  are  strong,  and  are  not  allowed  to  relax, 
pouch  out,  and  thus  favor  the  descent  of  the  organs 
(Fig.  8).  This  position  should  be  urged  during  child- 
hood, and  mothers  should  be  instructed  in  the  proper 
method  of  dressing  their  children  so  that  the  chest 
may   haye  the  freest  motion  without  meeting  with 


46 


THE  DIGESTIVE  APPARATUS. 


opposition  from  the  clothing.  All  garments  should 
be  suspended  from  the  shoulders,  to  prevent  the  down- 
ward displacement  of  the  stomach,  intestines,  kid- 
neys, liver,  etc.     Practically  all  women  stand  in  an 


Fig.  8. — Showing  the  shape  of 
the  abdomen  in  a  well-developed 
woman  standing  in  the  correct 
posture. 


Fig.  9. — Showing  the  shape  of 
the  abdomen  and  the  contours  of 
the  body  in  a  well-developed  case 
of  enteroptosis. 


improper  attitude,  a  fact  of  which  they  are  appar- 
ently ignorant.  Others  would  not  remain  ignorant 
of  the  fact  but  for  the  concealment  attending 
women's  dress.  That  this  is  no  exaggeration,  every 
physician  who  has  given  the  subject  careful   study 


CARRIAGE  AND  DRESS   INFLUENCrNG  DIGESTION.   47 

will  readily  agree  ;  but  the  fact  that  more  than  50  per 
cent,  of  all  civilized  women,  in  all  classes  of  life, 
have  developed  the  condition  known  as  enteroptosis 
(Fig.  9),  which  means  that  the  stomach,  intestines, 
very  often  the  kidneys,  and  sometimes  the  liver,  are 
dragged  downward  and  remain  permanently  out  of 
their  proper  position,  is  not  generally  known.  Such, 
however,  is  the  case  ;  and  this  condition  more  than 
any  other  cause  is  responsible  for  the  constipation, 
backache,  debility,  biliousness,  early  loss  of  com- 
plexion, headache,  and  that  long  list  of  ailments 
of  which  so  many  women  in  all  civilized  coun- 
tries are  victims.  Those  who  have  vigorous  con- 
stitutions, strong  nervous  systems,  and  who  keep 
the  body  in  a  healthy  tone  hy  leading  out-of-door 
lives  and  avoid  the  common  habits  of  worry  and  petu- 
lance, may  live  with  moderate  comfort  even  though 
suffering  from  the  enteroptosis  made  necessary  and 
permanent  by  the  methods  of  dress.  But  the  greater 
proportion  of  women  lack  these  sturdy  qualities,  and 
therefore  suffer  more  or  less  from  the  symptoms 
described.  Furthermore,  this  downward  dragging 
of  the  abdominal  organs  leads  to  displacements 
and  derangements  of  the  pelvic  organs,  and  the 
genito-urinary  diseases  so  common  in  women  are  a 
natural  result.  In  young  children  the  intestines 
have  not  yet  assumed  that  position  which  is  normal 
in  adult  life,  and  in  some  this  lack  of  development 
makes  a  constant  difficulty  in  evacuation  of  the 
bowels.  By  a  slow  process,  and  in  the  absence  of 
interference,  these  matters  in  time  right  themselves; 
but  not  infrequently  the  child  is  so  handicapped 
through    the   want   of  out-of-door   sports,     adequate 


48  THE  DIGESTIVE  APPARATUS. 

physical  training,  and  proper  methods  of  dress  that 
the  large  intestine  never  assumes  its  proper  place. 

Constipation  and  Diarrliea. — Downward  dis- 
placement of  the  bowels  not  only  leads  to  consti- 
pation, but  it  also  favors  a  catarrhal  state  of  the  intes- 
tinal lining,  leads  to  intestinal  indigestion,  and  occa- 
sionally produces  diarrhea,  and  sometimes  pain  and 
the  discharge  of  mucus  with  the  feces.  There  are 
other  reasons  aside  from  displacement  that  com- 
monly give  rise  to  constipation  and  other  unhealthy 
conditions  of  the  intestines,  important  among  which 
are  diet  and  habit. 

Influence  of  Diet. — It  has  been  said  that  the  cel- 
lulose of  fruits  and  vegetables  exercises  a  wholesome 
influence  upon  the  intestinal  mucous  membrane,  in- 
creasing the  bulk  of  the  contents  and  stimulating  the 
activity  of  the  secretions  of  the  intestinal  glands  and 
the  contraction  of  the  intestinal  muscles.  Formerly, 
when  the  use  of  coarser  foods  was  more  common  than 
at  present,  when  flour  and  meal  were  less  carefully 
bolted,  constipation  is  said  to  have  been  less  common. 
For  these  reasons  it  is  often  advised  that  those  who 
suffer  from  constipation  should  confine  themselves 
to  coarse  and  bulky  foods.  It  is  true  that  such 
a  diet  is  beneficial  to  one  class  of  people,  but  it  is 
harmful  to  another.  When  it  happens  that  the 
mucous  membrane  of  the  intestine  is  less  than  nor- 
mally irritable,  when  the  unstriped  muscle-tissue  is 
so  quiescent  that  it  fails  to  contract  from  the  stimulus 
offered  by  soft  and  semifluid  contents,  it  is  found  that 
both  the  secretion  and  motion  of  the  part  are  so  dimin- 
ished that  there  is  slowing  of  the  intestinal  stream, 
and  an  evacuation  does  not  occur  until  there  is  a  con- 


CONSTIPATION  AND  DIARRHEA.  49 

siderable  accumulation  in  the  colon.  Under  such 
conditions  the  bowel  is  usually  successful  in  empty- 
ing itself  unassisted,  but  only  irregularly  and  after 
improper  delay.  Such  stagnation  of  the  intestinal 
stream  is  injurious  to  the  intestine  and  to  the  organ- 
ism. To  the  former,  because  of  the  undisturbed  har- 
boring of  micro-organisms,  the  dulling  of  the  normal 
irritability  of  the  motor  and  secretory  nerves,  and  the 
weakening  of  the  intestinal  muscle  ;  to  the  latter, 
because  of  the  absorption  from  the  intestine  of  certain 
toxic  substances  that  are  much  more  likely  to  be 
formed  when  the  intestine  is  inactive.  These  toxic 
substances,  finding  their  way,  first,  to  the  liver  and 
then  to  the  general  circulation,  develop  those  symp- 
toms that  are  commonly  recognized  under  the  name 
of  biliousness.  This  term  has  come  to  have  a  broad 
meaning,  which,  indeed,  is  necessary,  as  the  expres- 
sions of  this  form  of  auto-intoxication  are  varied.  It 
will  be  understood  how  a  coarse  diet  may  be  very  ser- 
viceable in  relieving  the  condition  described  above. 
But  there  is  another  and  nearly  as  large  a  class  in  which 
the  mucous  membrane  and  muscle  of  the  intestine  are 
too  irritable.  This  results  sometimes  from  a  low  grade 
of  inflammation  affecting  the  superficial  lining  of  the 
intestine,  and  sometimes  to  over-impressionability  of 
the  nerves  of  the  part.  Under  such  circumstances  a 
bland,  unstimulating  diet  results  in  intestinal  contents 
that  excite  the  irritable  bowel  to  proper  activity;  but 
if  the  food  is  coarser  and  contains  much  vegetable 
fibers  or  husks  of  grain  it  causes  so  much  mechanical 
irritation  that  the  intestine  contracts  spasmodically 
and  prevents  the  normal  onward  movement  of  the 
feces.  These  influences  may  so  disturb  the  part  that 
4 


50  THE  DIGESTIVE  APPARATUS. 

over-secretion  and  over-motion  result,  and  a  diarrhea 
follows,  usually  to  be  succeeded  by  constipation,  and 
it  in  turn  by  diarrhea.  The  physical  condition  ac- 
companying either  one  of  these  states  may  not  be  so 
unlike  those  accompanying  the  other  ;  and  whatever 
course  of  living  most  tends  to  regularity  is  equally 
useful  in  the  prevention  of  diarrhea  and  constipation. 
It  so  happens  that  there  is  no  one  diet  that  is  suitable 
to  all  cases  of  constipation.  For  the  ordinary  indi- 
vidual it  is  a  mistake  to  restrict  the  diet  to  over- . 
refined  and  highly  nutritious  foods;  nor  should  the 
other  extreme  be  followed.  A  correct  blending  of 
coarse  and  fine  foods,  with  the  proper  proportion- 
ment  of  meats,  vegetables,  fruits,  fats,  starches,  and 
sugars,  is  the  diet  most  likely  to  agree  with  the  intes- 
tine as  well  as  the  stomach. 

The  influence  of  habit  is  equally  important  in 
evacuating  the  bowels  as  it  is  in  tjie  matter  of  eating. 
The  habit  of  having  a  regular  daily  movement  after 
the  morning  meal  should  be  cultivated.  Irregularity 
in  defecation,  usually  the  result  of  postponement  be- 
cause of  inconvenience,  is  one  of  the  most  successful 
means  of  inducing  constipation,  hemorrhoids,  and 
other  unnatural  states  of  the  intestine.  Few  realize 
that  the  digestive  apparatus  is  under  a  sensitive 
nervous  control,  and  does  not  tolerate  unphysiologic 
treatment  without  most  appreciable  resentment. 
While  infrequency  in  defecation  is  evidently  harmful, 
over-frequency  is  also  to  be  condemned.  For  the 
colon  to  contract  naturally  and  successfully  it  should 
have  a  certain  amount  of  contents  of  a  sufficient  con- 
sistency. Such  conditions  stimulate  a  regular  and 
progressive  contraction  of  the  bowels  and  a  successful 


THE   /N/'VA/KNCE    OF  I/.lB/y  5  I 

result.  Ill  children  the  amount  of  effort  put  forth,  the 
time  required  for  defecation,  and  the  form,  quantity, 
and  character  of  the  evacuation  should  be  carefully 
observed.  Tlie  dejections  are  normally  more  frequent 
in  the  young  than  in  the  adult.  Yet  even  in  children 
the  habit  of  going  to  stool  several  times  during  the 
day  should  be  discouraged.  There  is  a  certain  rhythm 
necessary  in  most  physiologic  processes,  and  this  is 
so  true  of  the  digestive  tract  that  disregard  of  the 
impulse  for  physiologic  defecation  is  to  establish  irreg- 
ularity and.  usually  suffering. 


HYGIENE  OF  THE  SKIN  AND  ITS 
APPENDAGES. 

By  GEORGE  HOWARD  FOX,  M.  D., 

OF  NEW  YORK, 
Clinical  Assistant,  Dermatological  Department,  College  of  Physicians  and  Surgeons. 


ANATOMY  AND  PHYSIOLOGY. 

The  skin  is  composed  of  two  layers,  a  superficial 
thin  layer,  called  the  epidermis  or  cuticle,  and  a  deep 
layer,  known  as  the  derma  cutis  or  true  skin. 

The  epidermis  is  readily  separable  from  the  derma, 
and  is  the  portion  of  skin  that  is  raised  by  the  fluid 
of  an  ordinary  blister.  Its  chief  function  is  to  give 
protection  to  the  underlying  true  skin  and  to  prevent 
it  from  drying  and  losing  its  natural  softness  and 
pliability.  The  epidermis  has  little  or  no  sensibility, 
and  in  this  respect  differs  from  the  true  skin,  which  is 
remarkably  sensitive  from  the  presence  of  many  deli- 
cate nerve-endings.  The  deeper  layer  of  the  epider- 
mis consists  of  cells  which  are  polygonal  in  shape 
and  moist  in  character,  and  is  called  the  mucous 
layer  or  rete  mucosum.  The  superficial  cells  are  dry 
and  flattened,  and  constitute  the  horny  layer  of  the 
epidermis.  There  is  a  constant  production  of  new 
cells  in  the  epidermis  taking  the  place  of  other  cells, 
which  are  pushed  toward  the  surface  and  finally  shed 
by  the  skin.  This  process  of  shedding  the  superficial 
dry  scales  is  constantly  taking  place,  and  is  aided  by 
the  rubbing  of  the  clothing  against  the  skin  and  by 
the  friction  employed  in  bathing.     This  desquamation 

52 


77//';    EPIDERMIS. 


53 


takes  place  in  the  form  of  iiiinute  scales.  Only  npon 
the  scalp  do  they  tend  to  become  visible  to  the  eye 
and  appear  as  flakes,  formin<r  a  condition  commonly 
known  as  dandrufif.  This  physiologic  shedding  of  the 
epidermis  when  not  in  excess  is  to  be  aided  by  bath- 
ing the  skin  and  shampooing  and  brushing  the  scalp. 


Hair 


Subcutaneous 
tissue 


Epidermis 


Derma 


Derma 


Fig.  io. — Vertical  microscopic  section  through  the  skin. 


In  the  deep  portion  of  the  mucous  layer  of  the  epi- 
dermis is  situated  the  pigment,  which  is  the  cause  of 
the  color  of  the  skin.  There  is  an  old  adage  that 
"color  is  only  skin  deep,"  but  in  fact  color  is  only 
one-half  skin  deep.  The  various  colors  of  the  skin  of 
the  different  races  of  mankind  are  due  to  the  varying 
amount  of  pigment  in  the  deep  layer  of  the  epider- 
mis.    Under  the  influence  of  the  sun's  rays  pigment 


54  THE  SKIN  AND  ITS  APPENDAGES. 

seems  to  be  most  readily  produced.  Not  only  are 
races  living  in  the  tropics  as  a  rule  much  darker 
than  the  inhabitants  of  a  cold  climate,  but  in 
this  temperate  climate  is  noticed,  in  the  form  of  tan 
and  freckles,  an  increased  production  of  pigment  oc- 
curing  in  summer.  Occasionally  the  function  of 
forming  pigments  ceases,  and  the  diseases  known  as 
vitiligo  and  albinism  result.  Vitiligo  is  character- 
ized by  white  spots,  most  frequently  seen  on  the  backs 
of  the  hands,  while  the  condition  known  as  albinism 
consists  of  a  total  absence  of  pigment  in  the  skin, 
hair,  and  eyes.  The  opposite  condition,  however,  is 
more  common,  namely,  the  production  of  too  much 
pigment,  as  seen  in  the  formation  of  freckles  and  the 
so-called  "  liver  spots"  or  "moth  patches." 

The  True  Skin  (Derma). — The  under  surface  of 
the  epidermis  is  uneven  and  dips  down  between  the 
prominences  of  the  derma  known  as  papillae.  The 
true  skin  is  the  organ  of  sensation,  and  the  nerve-end- 
ings giving  rise  to  sensations  of  touch,  pain,  and  tem- 
perature are  contained  in  these  little  hillocks  or 
papillae.  The  deeper  parts  of  the  skin,  together  with 
the  underlying  fat,  serve  as  a  protection  to  the  body 
against  violence. 

The  glands  in  the  skin  are  of  two  systems — the 
perspiratory  and  the  sebaceous  or  oil-producing. 

The  perspiratory  glands  consist  of  little  tubes 
ending  in  coils  lying  deep  in  the  true  skin  or  in  the 
fat  beneath.  An  outlet  or  duct  runs  in  a  spiral  man- 
ner to  the  free  surface  of  the  skin.  These  glands,  or 
pores,  as  the}^  are  popularly  termed,  are  found  every- 
where on  the  surface  of  the  body  and  are  present  in 
very  great  numbers.     It  has  been  calculated  that  the 


TJIK    J'/CA'S/'/A'ATORY  C LANDS. 


55 


entire  number  of  g-lands,  if  placed  end  to  end,  would 
cover  a  distance  of  twenty-eight  miles.  Next  to  the 
kidneys  the  perspiratory  glands  are  the  chief  means 
of  removing  water  from  the  system,  and  in  addition 
carry  away  various  other  waste-products.  P>esides 
being  an  organ  of  excretion,  the  skin,  by  means  of  its 
pores  or  perspiratory  glands,  performs  the  important 
function   of  regulation   of  the    body-temperature. 


Fig.  II. — Vertical  section  of  skin  :  si^^,  sebaceous  glands  ;  c/,  epidermis  ;  A, 
hair ;  d,  derma. 

When  the  body  is  at  rest  or  only  slightly  in  motion 
perspiration  is  constantly  taking  place  in  the  form  of 
a  vapor,  and  is  spoken  of  as  being  insensible.  When, 
however,  considerable  exercise  is  taken  the  pores  be- 
come more  active  and  produce  a  visible  amount  of 
perspiration,  which  is  termed  sensible.  The  condition 
of  the  atmosphere  greatly  influences  the  activity  of 
the  glands.     If  the  air  is  saturated  with  moisture,  the 


56  THE   SKIN  AND   ITS  APPENDAGES. 

perspiration  does  not  readily  evaporate,  but  remains 
upon  the  body.  If  the  air  is  dry,  and  especially  in 
motion,  the  perspiration  readily  evaporates  and  be- 
comes insensible. 

When  the  surrounding  air  is  much  warmer  than 
the  body  the  vessels  of  the  skin  dilate,  free  per- 
spiration takes  place,  and  by  its  evaporation  the 
body  becomes  cooled.  If  the  air  is  already  full  of 
moisture,  evaporation  of  the  perspiration  becomes 
very  difficult,  and  we  suffer  more  from  heat  than  if 
the  air  were  dry.  This  phenomenon  of  finding  hot 
weather  most  uncomfortable  when  humidity  is  pres- 
ent is  known  to  all  through  disagreeable  experience. 
It  is  for  the  same  reason  that  a  much  higher  tempera- 
ture can  be  born  in  the  Turkish  bath  where  the  air 
is  dry  than  in  the  hot  vapor  or  Russian  bath. 

When  the  air  is  cooler  than  the  body  the  blood-ves- 
sels contract  and  retain  the  warmth  of  the  body  by 
lessening  the  amount  of  blood  in  the  skin  to  be  cooled. 
Considering  the  purposes  subserved  by  the  perspiratory 
glands,  it  is  highly  important  to  remove  the  dry  scales 
of  the  epidermis  which  constantly  accumulate  and 
interfere  with  their  free  action.  While  this  is  par- 
tially accomplished  by  the  friction  of  the  clothing, 
nothing  will  take  the  place  of  systematic  bathing  if 
we  desire  to  keep  the  skin  in  a  perfectly  healthy  con- 
dition. 

While  the  perspiratory  glands  give  out  moisture,  it 
is  not  probable  that  they  absorb  any  appreciable 
amount  of  water  from  without,  as  experiments 
attempting  to  show  an  increase  of  weight  after  long- 
continued  immersion  in  water  have  proved  incon- 
clusive.    The  same  is  true  of  salt  in  solution,  and 


THE    OIL-PKODUCING    OR   SEBACEOUS   GLANDS.      5/ 

the  eflficacy  of  sea-bathing  in  giving  and  maintaining 
health  and  vigor  is  due  to  causes  other  than  tlie 
absorption  of  salt. 

The  oil-producing  or  sebaceous  glands  are 
found  in  all  parts  of  the  skin,  with  the  exception  of 
the  palms  and  soles,  and  are  especially  abundant  on 
the  face.  Under  the  microscope  they  appear  like 
small  sacs  situated  more  superficially  than  the  perspi- 
ratory glands,   and  opening  in  most  cases  into  the 


■■Mr* 


Fig.  12. — Transverse  section    of  skin    from  scalp,    showing   hairs   cut 
transversely  :  cp,  epidermis  ;  A,  hairs  ;  sbgl,  sebaceous  glands. 

little  pits  for  the  hairs  known  as  the  hair-follicles. 
They  secrete  a  greasy  substance,  for  the  purpose  of 
lubricating  the  skin  and  keeping  it  in  a  soft  and 
pliable  condition.  The  special  oil-glands  of  the  eye- 
lids prevent  adhesion  of  the  lids,  while  those  in  the 
scalp  form  a  natural  hair  oil  or  pomatum.  The  oil- 
glands  prevent  injurious  friction  of  opposing  sur- 
faces, and  the  oily  secretion  in  general  tends  to  pro- 
tect the  body  from  moisture,  as  it  does  in  the  case  of 
feathered  creatures. 


58 


THE   SKIN  AND   ITS  APPENDAGES. 


Although  the  hair  and  nails  appear  to  be  entirely 
different  in  structure  from  the  skin,  they  are  merely 
modifications  of  its  horny  layer. 

The  hair  consists  of  a  shaft  which  appears  above 
the  surface  of  the  skin,  and  a  root  which  is  placed  in 


Hair-shaft- 


Epidermis 


Derma 


Sebaceous  gland 

Medullary  substance  of  hair-shaft 

-  Cortical  sztbstance  of  hair-shaft 

Inner  root-sheath 

Outer  root-sheath 


Hair-bulb 
Hair-papilla 


Fig.  13. — Section  through  hair  and  follicle. 


a  socket  or  inversion  of  the  skin,  called  the 
hair-follicle.  At  the  bottom  of  the  follicle  the  hair 
and  the  various  layers  of  the  skin  are  found  to  be 


THE  HAIR.  59 

continuous.  The  substance  of  the  hair  consists  of 
three  different  layers,  and  has  been  compared  to  the 
trunk  of  a  tree.  The  main  portion  of  the  hair,  tlie 
fibrous  portion,  is  comparable  to  the  dense  wood  of 
the  tree,  and  consists  of  flattened  and  elongated  cells. 
It  constitutes  the  main  bulk  of  the  hair.  The  central 
portion,  or  pith,  consists  of  cells  nearly  spherical  in 
shape.  The  outermost  layer  of  the  hair  consists  of 
flat  cells  which  overlap  one  another  like  tiles  on  a 
roof,  and  to  this  fact  is  due  the  rough  feeling  when  a 
hair  is  pulled  between  the  fingers  from  the  point 
toward  the  root.  The  property  of  "  felting"  is  also 
due  to  this  peculiar  saw-like  surface  of  hair.  By  the 
same  arrangement  a  loose  hair  may  at  times  work  its 
way  into  a  wound. 

The  color  of  hair  depends  upon  the  presence  of 
pigment  in  the  pith  and  fibrous  layer,  and  upon  the 
presence  of  minute  bubbles  of  air.  The  greater  part 
of  the  body  is  covered  with  fine,  downy  hairs,  whose 
roots  extend  but  a  short  distance  in  the  skin,  while 
the  roots  of  the  large  stiff  hairs  extend  into  the  fat 
beneath  the  skin. 

The  hair  serves  various  useful  purposes,  besides 
being  a  very  great  adornment  to  the  human  body. 
It  protects  the  head  against  the  sun's  rays  and 
against  violence,  and  affords  a  very  considerable 
amount  of  warmth.  The  eyelashes  protect  the  eyes 
against  the  entrance  of  foreign  matters,  and  the  stiff 
hairs  of  the  ear  and  nose  prevent  intrusion  of  insects 
and  foreign  bodies.  The  moustache  is  supposed  to 
act  as  a  filter  of  the  air  that  is  breathed,  while  the 
beard  is  said  to  serve  the  purpose  of  protecting  the 
throat  from  cold. 


6o  THE  SKIN  AND   ITS  APPENDAGES. 

The  nail  consists  of  modified  horny  tissue  lying 
upon  the  nail-bed,  which  is  a  portion  of  the  true 
skin.  The  nail  itself  corresponds  to  the:  epidermis  in 
this  region.  The  sides  and  root  of  the  nail  are 
embedded  in  folds  of  skin,  while  its  end  is  free. 
Near  the  root  of  the  nail  is  seen  a  semilunar  area, 
which  is  more  opaque  than  the  rest  of  the  nail,  due 
to  a  scarcity  of  blood-vessels  in  this  situation. 

The  nail  itself  has  no  color  and  is  bloodless.  Its 
apparent  color  is  due  entirely  to  the  vascularity  of 
the  nail-bed  beneath,  which  shines  through  the 
translucent  substance.  The  growth  of  the  nail  takes 
place  at  its  root  by  constant  formation  of  new  cells 
pushing  the  nail  forward.  If,  however,  an  obstacle  to 
its  forward  growth  is  offered  by  a  tight-fitting  shoe 
sooner  or  later  the  nails  will  begin  to  grow  into  the 
flesh,  and  the  painful  condition  of  ingrowing  nail 
will  be  the  result. 

The  discussion  of  the  hygiene  of  the  skin  naturally 
involves  a  number  of  important  subjects,  prominent 
among  which  are  food,  exercise,  bathing  and 
clothing.  As  food  and  exercise  are  treated  else- 
where in  this  work,  it  need  only  be  mentioned  here 
that  the  maintenance  of  the  skin  in  a  healthful 
condition  depends  largely  upon  a  judicious  dietary  and 
systematic  exercise,  while  the  attention  of  the  reader 
is  particularly  invited  to  the  subjects  of  regular  bath- 
ing and  proper  clothing. 

BATHING. 

While  discussing  the  physiology  of  the  skin  it  was 
shown  how  the  superficial  scales  of  the  epidermis 
tend  to  collect,   and  with   the  sebaceous  matter  and 


BATJUNC.  6 1 

dirt  to  form  a  pellicle  which  interferes  witli  the  proper 
functions  of  the  perspiratory  glands.  Bathing  re- 
moves this  pellicle  and  is  an  important  factor  in 
maintaining  a  healthy  skin.  In  addition  it  has  a  very 
beneficial  effect  upon  the  general  health,  as  the  skin 
is  intimately  connected  with  the  internal  organs  by 
means  of  the  nervous  system. 

Classification  of  Baths. — Baths  are  often  spoken 
of  as  local  or  general,  according  as  the  ablution  is 
confined  to  a  portion  or  the  whole  of  the  body. 
Again,  they  may  be  classified  according  to  tempera- 
ture as  follows  :  hot,  over  98° F  ;  warm,  between  90° 
and  98°  F. ;  tepid,  between  80°  and  90°  F. ;  cool,  be- 
tween 65°  and  80°  F. ;  and  cold,  below  65°  F.  These 
are  merely  arbitrary,  but  convenient  distinctions.  For 
practical  purposes  it  will  be  sufficient  to  describe  the 
cold,  the  warm,  and  the  tepid  bath. 

The  cold  bath  is  intended  to  act  as  a  stimulant 
and  give  strength,  as  opposed  to  the  warm  bath, 
which  has  a  soothing  action,  or,  technically 
speaking,  is  sedative.  The  proper  time  to  take  a 
cold  bath  is  before  breakfast  and  as  soon  after  ris- 
ing as  convenient.  A  simple  and  by  no  means  in- 
effective way  of  taking  the  morning  bath  is  with 
the  sponge,  for  the  conveniences  of  a  shower  bath 
or  tub  are  not  always  at  hand.  Every  one,  however, 
may  possess  a  sponge  and  a  bowl  of  cold  water,  and 
will  derive  health'  and  enjoyment  from  their  daily 
use.  Considering  the  fact  that  cold  baths  are  so  bene- 
ficial and  pleasant,  as  those  who  take  them  regularly 
will  affirm,  it  seems  strange  that  in  this  country 
at  least  such  a  small  number  of  persons  indulge  in 
them.    Many  say  that  they  cannot  take  the  cold  bath, 


62  THE   SKIN  AND  ITS  APPENDAGES. 

as  it  gives  them  too  great  a  shock,  or  is  too  weak- 
ening, or  is  not  followed  by  a  proper  reaction. 
On  the  contrary,  however,  most  persons  can  take  .a 
cold  bath  every  morning  if  they  will  only  make  up 
their  minds  to  do  so  and  go  about  it  properly.  It  would 
not,  of  course,  be  advisable  for  one  advanced  in  years, 
when  the  blood-vessels  are  naturally  weak,  to  risk  apo- 
plexy by  plunging  into  a  cold  bath  without  being 
properly  trained  to  it  by  gradual  stages. 

The  physiologic  action  of  the  cold  bath  is  to  con- 
tract the  cutaneous  vessels  and  to  drive  the  blood  to 
the  internal  organs,  causing  a  pallor  of  the  skin. 
The  respiration  is  greatly  increased  in  depth,  quick- 
ened at  first  and  then  slowed.  The  frequency  of  the 
pulse  is  lessened  and  the  temperature  somewhat 
lowered.  The  nervous  system  and  especially  the 
mental  faculties  are  immediately  and  very  power- 
fully stimulated.  Upon  emerging  from  the  bath,  if 
the  reaction  takes  place,  the  tiny  arteries  dilate  and 
cause  the  skin'  to  be  flushed,  the  pulse  and  respira- 
tion soon  become  normal,  and  the  bather  experiences 
very  quickly  a  sensation  of  warmth  and  general  well- 
being.  This  reaction  is  the  test  of  prime  importance 
as  to  whether  or  not  the  bath  is  well  borne.  With 
practised  bathers  it  will  take  place  very  speedily,  and 
a  delightful  feeling  of  warmth  will  very  soon  be  the 
reward  of  having  for  a  moment  braved  the  cold 
water.  After  leaving  the  bath,  in  order  to  aid  the 
reaction  the  bather  should  rub  the  body  from  head 
to  foot  with  a  rough  towel  till  the  skin  fairly  glows, 
and  when  entirely  dry  the  clothing  may  be  put  on 
without  delay. 

While  most  persons  are  able  to  take  cold  baths, 


THE    WARM  BATH.  63 

tliey  should  become  accustoinetl  to  llieni  gradually. 
Not  only  will  well  persons  maintain  their  health  and 
strength,  but  many  in  poor  health,  and  especially 
those  of  a  nervous  temperament,  will  derive  much 
good  from  the  daily  cold  bath.  The  best  time  to  be- 
gin systematic  cold  bathing  is  in  the  warmer  months, 
and  by  the  time  winter  arrives  they  can  be  kept  up 
with  very  little  trouble  or  discomfort.  If  the  bather  has 
not  the  conveniences  of  a  tub,  or  fears  such  a  decided 
change  as  a  tub  bath,  it  is  well  to  begin  with  a  cold 
sponge  bath.  The  sponge  should  be  saturated  with 
cold  water  and  squeezed  over  the  arms,  then  over  the 
chest  and  back,  and  finally  over  the  legs,  after  which 
a  vigorous  rubbing  should  be  taken.  The  tempera- 
ture of  the  water  can  be  raised  somewhat  at  first,  and 
gradually  lowered  as  the  bather  becomes  more  ac- 
customed to  the  cold  water.  The  temperature  of  the 
water  should  not  be  so  extremely  low,  however,  as 
to  interfere  with  a  thorough  and  speedy  reaction.  A 
very  beneficial  way  of  taking  the  morning  cold  bath 
is  by  means  of  the  shower,  which  is  stimulating 
through  the  impact  of  the  water  against  the  skin  as 
well  as  through  its  temperature.  Nothing  quite  equals 
the  full  tub  bath,  however,  if  the  bather  will  begin  with 
water  only  moderately  cold,  or  will  first  become  ac- 
customed to  the  sponge  bath,  and  then  change  to  tub 
baths.  One  of  the  most  benefical  results  of  cold 
baths  is  the  almost  universal  immunity  to  catching 
cold,  as  every  one  who  takes  a  cold  bath  daily  will 
declare. 

The  Warm  Bath. — The  cold  and  the  warm  baths 
are  almost  directly  opposite  in  their  physiologic 
action  and  purposes.     The    warm  bath    dilates  the 


64  THE  SKIN  AND  ITS  APPENDAGES. 

tiny  arteries,  as  is  shown  by  redness  of  the  skin,  and 
causes  profuse  perspiration.  The  pulse  and  respira- 
tion are  increased  in  frequency  and  the  temperature 
is  raised.  The  warm  bath  has  an  extremely  soothing 
effect  on  the  nervous  system,  and  for  this  reason  is 
best  taken  at  night  before  retiring.  The  perspira- 
tion which  is  likely  to  continue  after  a  warm  bath  is 
disagreeable  to  some,  and  may  be  prevented  by  spong- 
ing the  body  with  cold  water  at  the  end  of  the  bath. 
After  an  unusual  amount  of  physical  labor,  when  the 
muscles  are  sore  and  aching,  nothing  is  more  wel- 
come or  soothing  than  a  warm  bath.  The  blood  is 
withdrawn  from  the  muscles,  lessening  chemic 
change,  and  pain  and  soreness  vanish  speedily.  In 
addition  to  removing  muscular  soreness  and  pain,  the 
warm  bath  is  relaxing  and  tends  to  relieve  spasmodic 
conditions  or  cramps.  For  those  who  suffer  from 
difficulty  in  getting  to  sleep,  a  warm  bath  just  before 
retiring  will  often  invite  a  refreshing  slumber. 
While  the  warm  bath  is  to  be  highly  recommended 
as  a  means  of  relieving  weariness  after  prolonged 
physical  exertion,  under  no  circumstances  should  a 
cold  bath  be  taken  at  this  time. 

The  hot  bath  (above  98°  F.)  should  not  be  taken 
except  upon  the  advice  of  a  physician. 

The  tepid  bath  has  no  decided  physiologic  effect 
and  is  generally  employed  for  cleansing  purposes.  It 
may  be  taken  any  time  during  the  day,  though  pref- 
erably in  the  afternoon  or  just  before  bedtime. 

The  proper  time  to  bathe  is  just  before  a  meal  or 
about  three  hours  after.  In  order  to  digest  food 
properly  the  stomach  needs  an  abundant  supply  of 
blood  to  form  its  necessary  juices  and  ferments,  and 


SOAP.  65 

if  the  blood  is  diverted  from  the  stomach  to  the  sur- 
face of  the  body  by  means  of  a  bath  the  digestion 
will  necessarily  suffer. 

Soap. — As  water  alone  cannot  dissolve  the  grease 
upon  the  skin,  the  use  of  soap  is  essential  in  order  to 
effect  a  thorough  cleansing.  Soap  is  a  combination 
of  a  fat  with  an  alkali  in  greater  or  less  excess.  The 
latter  combines  with  the  fat  of  the  skin,  rendering  it 
soluble  and  freely  miscible  with  water.  Potash  is 
the  alkali  used  to  form  soft  soap,  while  a  hard  soap  is 
produced  by  combining  the  fat  with  soda.  A  soap  is 
said  to  be  neutral  when  the  alkali  nearly  balances  or 
is  in  very  slight  excess  of  the  fat,  and  in  this  class  are 
included  most  of  our  ordinary  toilet  soaps.  A  good 
soap  should  be  made  of  pure  and  fresh  fat,  should  not 
contain  too  much  alkali,  which  tends  to  irritate  and 
roughen  the  skin,  and  the  percentage  of  water  should 
not  be  so  high  as  to  cause  unnecessary  waste.  Adul- 
teration with  foreign  substances,  such  as  silica,  which 
is  added  to  increase  the  bulk,  should  be  avoided. 

The  harm  actually  done  by  impure  soaps  is  very 
small  in  proportion  to  the  amount  of  fear  and  appre- 
hension expressed  concerning  their  use.  No  one 
stops  to  ask  just  what  special  make  of  bread  is  pure, 
but  continues  to  eat  whatever  bread  appears  to  be 
wholesome  and  palatable  ;  and  similarly  any  toilet 
soap  upon  the  market  may  be  used  with  impunity  by 
the  majority  of  people.  A  soap  that  will  form  a 
large  amount  of  lather  is  not  on  that  account  valu- 
able, for  cocoanut  oil  is  often  added  to  produce  this 
result.  The  expense  of  a  soap  is  a  better  test  of  its 
value,  as  a  good  soap  cannot  be  made  very  cheaply. 
The  various  soaps  that  are  claimed  to  have  soothing 
5 


dd  THE  SKIN  AND  ITS  APPENDAGES. 

properties  are  not  to  be  recommended  on  that  account, 
as  the  most  that  is  desired  of  a  soap  is  that  it  shall  be 
simply  pure  and  non-irritating. 

Medicated  soaps  are  of  little  use,  although  great 
hopes  were  expressed  as  to  their  usefulness  when  first 
introduced.  No  special  therapeutic  value  can  reside  in 
a  substance  like  soap  which  is  intended  to  come  in 
contact  with  the  skin  for  such  a  short  space  of  time. 
Tar  soap  has  attained  a  considerable  popularity,  espe- 
cially for  use  in  shampooing  the  head.  For  this  pur- 
pose it  is  generally  pleasant  and  effective,  but  with 
the  exception  of  a  strong  odor  it  cannot  be  said  to 
possess  any  very  unusual  quality- 
Sea-bathing. — There  are  numerous  causes  that 
tend  to  make  sea-bathing  beneficial  to  the  health,  as 
well  as  a  pleasure  to  the  majority  of  people.  ^  The 
very  fact  that  a  bath  in  the  ocean  is  enjoyable  will 
increase  its  beneficial  effect,  and,  indeed,  any  exercise 
or  recreation  will  be  of  greater  benefit  if  undertaken 
cheerfully  and  not  considered  as  a  tiresome  matter  of 
duty.  The  fine,  pure  air  of  the  seashore  constitutes 
one  of  the  important  advantages  to  be  derived  from 
sea-bathing.  Breezes  from  the  ocean  are  always  fresh 
and  free  from  micro-organisms,  and  constitute  an 
invigorating  tonic  for  healthy  as  well  as  for  many 
sickly  persons.  The  shock  of  the  cold  bath  is  always 
lessened  by  the  exercise  taken,  especially  if  the 
bather  can  swim.  The  motion  of  the  waves  acts  as  a 
sort  of  massage  to  the  body  and  adds  invigoration  to 
the  bath. 

It  is  rather  doubtful  whether  any  special  virtue 
resides  in  the  large  amount  of  salt  and  greater  density 
of  sea  water.     It  has  been  remarked  that  very  little  if 


THE    rUKKISII  OR  HOT- AIR  liAJV/.  6y 

any  salt  can  be  absorbed  through  the  skin,  and  this 
alleged  advantage  of  sea-bathing  is  probably  mostly 
in  the  mind  of  the  bather.  Many  persons  abuse  the 
privilege  of  bathing  in  the  ocean  by  remaining  in  the 
water  until  their  fingers  and  lips  are  blue  and  teeth 
are  chattering.  All  are  not  alike  in  their  ability  to 
bear  cold  water,  and  convalescents  or  persons  with 
serious  organic  disease  should  bathe  only  under  medi- 
cal supervision.  No  one  should  remain  in  the  bath 
until  thoroughly  chilled.  Ten  to  twenty  minutes 
should  constitute  the  range  of  duration. 

No  one  should  attempt  to  plunge  into  the  water 
suddenly  when  overheated,  and  if  there  is  any  con- 
siderable perspiration  it  is  well  to  sponge  oflf  the  body 
with  cold  or  cool  water  before  beginning  the  bath. 
The  morning  is  the  most  appropriate  time  to  take  the 
daily  bath  in  the  ocean,  as  its  general  purpose  is  to 
be  invigorating,  and  it  is  also  most  conveniently  taken 
when  the  water  is  at  high  tide.  After  bathing  in  the 
salt  water  many  find  it  agreeable  to  take  a  brief 
shower  or  sponge  bath  of  fresh  water.  When  the 
bath-house  is  provided  with  an  inner  courtyard  it  is 
healthful  and  advisable  for  the  bather  to  lounge 
about  in  the  sun  for  a  while  and  allow  the  air  as 
well  as  sunlight  to  come  in  contact  with  the  skin,  and 
then  to  don  the  clothing  leisurely. 

The  word  "  bath  "  does  not  always  refer  to  an  ablu- 
tion with  water,  but  in  a  broader  sense  means  surround- 
ing the  body  with  any  medium  whose  quality  or  tem- 
perature is  unusual.  Thus  we  speak  of  the  hot-air 
bath,  the  hot-vapor  bath,  the  compressed-air  bath,  etc. 

The  Turkish  or  hot-air  bath  serves  several  useful 
purposes,  and  is  well  borne  by  the  average  healthy 


68  THE  SKIN  AND  ITS  APPENDAGES. 

person.  Its  systematic  use  may  at  times  be  advan- 
tageous, although  it  is  for  many  an  expensive  luxury 
and  not  accessible  outside  of  cities.  In  taking  a 
Turkish  bath,  the  bather,  after  removing  his  clothing, 
enters  the  warm  room  where  the  temperature  is  only 
a  little  above  that  of  the  body.  Here  he  remains  for 
a  short  time  till  a  gentle  perspiration  appears  upon 
the  skin.  He  next  enters  the  hot  room,  where  the 
temperature  ranges  from  120°  to  140°  F.,  and  some- 
times a  still  hotter  room  is  provided  where  the  tem- 
perature may  exceed  170°  F.  Upon  entering  the  hot 
room  the  inexperienced  bather  often  feels  a  sensa- 
tion of  nausea  or  suffocation;  but,  as  a  rule,  in  a  well- 
ventilated  bath  these  uncomfortable  feelings  will  van- 
ish with  the  appearance  of  a  free  perspiration.  A 
practised  bather  will  suffer  no  inconvenience  in  the 
hot  room,  and  will  perspire  much  more  freely  and 
much  more  quickly  than  the  beginner.  By  drinking 
a  glass  of  water  before  or  during  the  bath  the  produc- 
tion of  perspiration  is  greatly  aided.  After  leaving 
the  hot  room  the  bather  is  shown  to  a  moderately  cool 
room  and  reclines  while  the  attendant  lathers  him 
from  head  to  foot  and  scrubs  and  massages  him  vigor- 
ously. This  removes  all  the  dried  epithelial  scales, 
and  as  a  means  of  cleansing  the  skin  it  may  be  said 
that  the  Turkish  bath  is  without  an  equal.  The  soap 
is'  removed  by  a  douche,  beginning  with  warm  and 
ending  with  cold  water.  The  bather  may  then  take 
a  plunge  in  a  tank  of  cold  water  if  this  is  afforded  by 
the  establishment,  or  immediately  repair  to  a  cool 
room  and  recline  for  a  half  hour  or  more  wrapped  in 
a  blanket.  For  persons  who  are  exhausted  from 
great  exertion  and  whose  muscles  and  joints  are  sore 


hA  77/-  /Vv'  UIUTUS.  69 

and  stiff  the  Turkisli  Imtli  is  most  rcfrcsliing.  Many 
sufferers  from  rheumatism  will  derive  relief  from  a 
systematic  course  of  such  baths.  The  Turkish  bath 
is  often  successfully  resorted  to  for  breaking  up  a 
cold. 

The  Russian  bath  differs  from  the  Turkish  bath  in 
substituting  hot  vapor  for  the  hot  air  of  the  latter. 
Perspiration  cannot  take  place  as  readily  in  the  Rus- 
sian bath  as  has  been  explained,  and  for  producing 
a  copious  perspiration  the  Russian  bath  is  inferior  to 
the  Turkish.  It  is  employed  in  some  cases  of  chronic 
rheumatism,  and  is  especially  beneficial  for  dry  forms 
of  bronchitis. 

Bath-pruritus. — A  recent  writer  speaks  of  a  dis- 
agreeable and  annoying  result  occasionally  produced 
by  bathing,  which  he  calls  "bath-pruritus."  He  de- 
scribes it  as  a  sensation  of  burning,  or  more  often  itch- 
ing, chiefly  confined  to  the  lower  extremities,  which 
appears  very  shortly  after  an  ablution.  Its  duration 
varies  from  a  few  minutes  to  a  half  hour.  It  may 
follow  bathing  in  salt  or  in  fresh  water.  The  itching 
seems  to  be  aggravated  by  too  long  continuance  or 
extremes  of  temperature  of  the  bath;  by  the  use  of 
soap  that  is  too  strong  or  is  allowed  to  remain  upon 
the  skin.  Indulgence  in  scratching  seems  to  increase 
the  pruritus.  The  writer  further  states  that  the  affec- 
tion is  likely  to  occur  in  persons  with  a  naturally 
irritable  skin  and  a  tendency  to  urticaria  or  hives. 
This  statement  suggests  sufficient  cause  for  the 
majority  of  cases  of  this  so-called  bath-pruritus.  In- 
deed most  persons  who  suffer  from  itching  after  a  bath 
must  look  for  the  cause  in  a  natural  irritability  of 
the  skin  rather  than  in  the  bath  itself. 


yO  THE   SKIN  AND   ITS  APPENDAGES. 

The  treatment,  which  is  not  always  satisfactory,  is 
based  upon  general  principles.  Any  digestive  or 
nervous  disturbances  are  to  be  corrected,  and  a  re- 
stricted diet  and  plenty  of  exercise  are  to  be  advised. 
The  intestinal  action  should  be  rendered  free  by  lax- 
ative food  or  medicine.  The  bath  should  not  be  of 
too  long  duration,  and  for  cleansing  the  skin  a  good 
toilet  soap  should  be  employed.  After  the  bath  it  is 
well  to  dry  the  skin  gently  without  friction,  and  then 
to  apply  freely  some  dusting-powder,  such  as  equal 
parts  of  starch  and  zinc  oxid. 

Care  of  the  Complexion. — From  the  exposure  to 
which  the  face  is  naturally  subjected  it  should  receive 
no  less  than  two  daily  ablutions.  Cold  water  should 
be  used  for  washing  the  face,  as  it  has  a  stimulant 
action  on  the  blood-vessels  and  improves  the  circula- 
tion in  the  skin.  It  also  improves  the  tone  of  the 
elastic  fibers  of  the  skin  and  tends  to  delay  the  appear- 
ance of  wrinkles.  Furthermore,  the  general  sensa- 
tion of  bathing  the  face  with  cold  water  is  most 
refreshing.  If  the  water  is  so  cold  as  to  be  disagree- 
able, its  temperature  may  be  raised  slightly  ;  but  it  is 
not  advisable  to  use  hot  or  warm  water  regularly  for 
washing  the  face.  Using  hot  water  upon  the  face 
and  then  undergoing  exposure  to  cold  air  or  wind, 
especially  in  winter,  has  a  decided  tendency  to  pro- 
duce chapping  and  roughening  of  the  skin. 

It  is  a  question  as  to  whether  the  use  of  soap  is 
advisable  for  the  daily  cleansing  of  the  face.  For  the 
perfectly  healthy  skin  soap  is  not  absolutely  essen- 
tial, and  its  too  frequent  use  may  prove  injurious. 
For  persons,  however,  with  a  very  oily  skin,  or  for 
those  residing  in  cities  where  the  air  is  laden  with 


TOILET  LOTIONS.  7  I 

soot  from  the  use  of  soft  coal,  the  daily  use  of  soap 
may  be  necessary.  If  the  complexion  is  sallow  and 
there  is  a  tendency  to  pimples  and  blotches,  nothing 
will  serve  better  to  stimulate  the  circulation  and  to 
improve  the  complexion  than  vigorous  i)inching  of 
the  face  by  the  fingers. 

Questions  are  frequently  asked  regarding  the  advis- 
ability of  using  various  toilet  creams  and  lotions  on 
the  face,  and  about  the  use  of  the  various  complexion 
or  face  powders.  If  the  skin  is  unnaturally  dry,  there 
can  be  no  harm  in  the  application  of  a  little  grease  to 
the  face,  while  the  employment  of  powder  is  largely 
a  matter  of  taste.  In  hot  weather  the  application  of 
a  small  quantity  of  rice  powder  to  the  face  will  often 
be  grateful,  and  can  do  no  harm  to  the  complexion. 

The  preparations  known  as  cold  creams  are  mixt- 
ures of  some  solid  fat  as  wax  or  spermaceti,  with  an 
oil  such  as  castor  or  almond  oil,  to  which  some 
fragrant  substances  are  added.  They  can  be  used  on 
the  face  with  perfect  freedom  and  without  danger  of 
injury.  The  toilet  or  face  creams  are  mucilaginous 
preparations  containing  tragacanth  and  other  ingre- 
dients, and  are  pleasant  applications  for  a  fissured  or 
chapped  skin. 

Toilet  lotions  serve  a  similar  purpose,  and  are  gen- 
erally transparent  preparations  containing  ghcerin 
and  other  substances. 

For  removing  summer  freckles  and  tan  the  follow- 
ing lotion  may  be  employed  : 


R. 

— Siilphocarbolate  of  soda, 

50  grains 

Glj'cerin, 

2  ounces 

Rose-water, 

I  ounce  ; 

Alcohol, 

I  ounce. 

72  THE  SKIN  AND  ITS  APPENDAGES. 

For  an  obstinate  case  of  freckles  the  following  may 
be  recommended  : 


R. 

— Bichlorid  of  mercury, 

6  grains  ; 

Alcohol, 

I  ounce ; 

Glycerin, 

2  ounces 

Oil  of  lavender, 

lo  drops. 

Face  powders  are  generally  composed  of  one  or 
more  of  the  following  substances  :  Talcum,  starch, 
bismuth,  chalk,  zinc  oxid,  and  magnesia,  and,  as  a 
rule,  are  entirely  harmless.  Lead  has  at  times  been 
employed  as  an  ingredient  of  face  powders,  and  if  the 
powder  contains  this  substance  it  is  objectionable  from 
the  possibility  of  a  poisonous  effect. 

CLOTHING. 

The  materials  most  frequently  used  for  clothing  are 
derived  partly  from  the  animal  and  partly  from  the 
vegetable  kingdom.  From  the  former  are  obtained 
silk,  wool,  furs,  and  leather,  while  from  the  latter  are 
derived  cotton,  linen,  and  rubber.  In  discussing  the 
value  of  these  different  substances  as  materials  for 
clothing,  two  important  physical  properties  to  be 
considered  are  their  power  of  conducting  heat  and 
capacity  for  absorbing  moisture. 

The  heat-conducting  power  which  a  garment 
possesses  does  not  depend  to  any  great  extent  on  the 
fabric  itself,  but  chiefly  on  the  manner  in  which  that 
fabric  is  woven.  Dry  air  is  a  very  poor  conductor  of 
heat,  and  any  garment  which  is  loosely  woven  and  is 
capable  of  holding  considerable  air  in  its  meshes  will 
be  a  poor  conductor,  and  will  consequently  feel  warm. 
Wool,  for  the  reason  that  it  is  naturally  woven  into 
cloth  that  is  loose  in  texture  and  porous,  is  a  most 


CLOTHING.  73 

valuable  clothing  material  for  use  in  cold  weather. 
If  numerous  thicknesses  of  woollen  clothing  will  not 
suffice  to  withstand  severe  cold,  then  furs  may  be 
supplemented.  Cotton  is  naturally  woven  into  cloth 
whose  texture  is  compact  and  not  porous,  and  is, 
therefore,  not  so  valuable  as  wool  for  use  in  cold 
weather.  When,  however,  specially  manufactured 
so  that  its  texture  closely  resembles  that  of  woollen 
cloth,  it  may  be  a  fair  substitute  for  wool. 

The  capacity  for  absorbing  moisture  is  possessed 
by  wool  to  a  very  high  degree,  silk  being  next  to 
wool  in  this  respect.  Linen  is  only  moderately,  and 
cotton  very  slightly,  hygroscopic.  A  woollen  gar- 
ment has  the  property  of  absorbing  a  great  deal  of 
moisture  without  feeling  wet.  Evaporation  of  moist- 
ure proceeds  slowly  from  woollen  clothing,  while 
cotton  clothing,  especially  underwear,  speedily 
becomes  saturated  with  moisture  and  evaporation  is 
liable  to  take  place  suddenly,  with  resulting  chilling 
of  the  body.  In  speaking  of  flannel,  some  philosopher 
has  made  the  paradoxical  remark  that  no  matter  how 
cold  and  wet  it  may  be  it  is  always  warm  and  dry. 
As  flannel  underclothing  is  so  hygroscopic  and  does 
not  allow  the  moisture  it  absorbs  to  evaporate  too 
rapidly,  it  is  the  most  valuable  material  for  under- 
clothing for  use  in  temperate  and  changeable  climates. 
For  cold  weather,  heavy  woollen  underwear  cannot  be 
surpassed  for  warmth  and  comfort.  By  manufactur- 
ing cotton  into  cloth  with  large  meshes  or  air-con- 
taining spaces  a  very  fair  substitute  for  flannel 
underwear  has  been  obtained.  While  probably  not 
superior  to  flannel  for  underclothing,  this  material  is 
valuable  for  persons  who  find  wool  next  to  the  skin 


74  THE   SKIN  AND   ITS  APPENDAGES. 

uncomfortable.  Many,  however,  who  think  at  first 
that  they  cannot  bear  wool  next  to  the  skin  will, 
after  awhile,  tolerate  its  presence.  Another  substi- 
tute for  woollen  underwear  is  found  in  merino,  which 
consists  of  a  mixture  of  wool  and  other  materials. 

Woollen  underclothing  has  the  disadvantages  of 
shrinking  readily  when  washed  and  of  absorbing 
odors  readily.  The  former  fault  can  be  somewhat 
overcome,  however,  by  buying  goods  which  have 
been  shrunken  and  by  having  them  washed  in  tepid 
water,  with  little  soap  and  no  violent  friction.  On 
account  of  this  tendency  to  shrink,  old  flannel  under- 
clothing is  not  the  equal  of  new,  for  after  repeated 
washing  the  fabric  becomes  "  felted,"  less  porous  and 
of  a  closer  texture,  and  consequently  not  so  warm. 

Clothing  for  Cold  Weather. — It  is  a  mistake  to 
try  to  endure  cold  w'eather  without  wearing  sufii- 
ciently  warm  clothing.  Whenever  a  feeling  of  cold 
or  chilliness  is  experienced  it  is  highly  proper  to 
put  on  an  extra  garment  without  delay,  and  it 
is  folly  to  w^ait  till  the  body  is  chilled  before  taking 
the  trouble  to  make  a  change  of  clothing.  The  habit 
of  wearing  thin  clothing  all  the  year  round  and  of 
going  without  an  overcoat  through  the  winter  to  dis- 
play a  vigorous  constitution  is  not  advisable.  It  is 
true  that  some  persons  seem  to  keep  well  from  such 
a  course,  and  while  the  heat-producing  power  may 
be  equal  to  the  extra  demand,  it  is  at  the  expense 
of  the  nervous  energy  of  the  individual.  Children 
and  old  people,  whose  power  of  producing  heat  is  lim- 
ited, should  be  proportionately  warmly  clad,  and  the 
practice  of  dressing  children  with  the  legs  exposed  is 
as  cruel  as  it  is  unhvo-ienic. 


CLOTHING   J'OK    WARM    WEATHER.  75 

Clothing  fbr  Warm  Weather. — For  use  in  tropical 
climates  flannel  underwear  is  found  to  be  too  warm, 
and  cotton,  silk,  and  linen  are  more  serviceable  ma- 
terials. The  Chinese  plan  of  wearing  a  net  next  to 
the  skin,  and  over  it  a  thin  silken  garment,  is  ad- 
mirable, the  silk  readily  absorbing  the  perspiration, 
while  the  net  prevents  the  silken  garment  adhering  to 
the  skin.  Silk  underclothing  is  always  agreeably 
soft  and  fresh,  but  it  is  expensive  and  is  likely  to 
shrink  considerably  in  washing.  Much  of  the  under- 
clothing said  to  be  pure  silk  is  probably  of  mixed 
composition.  Thin  linen  for  tropical  wear  is  said  to 
be  very  acceptable  and  always  has  a  feeling  of  fresh- 
ness, but  it  is  more  expensive  than  cotton,  which  is 
for  practical  purposes  the  most  available  material  to 
be  employed.  Cotton  cloth  is  strong,  durable,  cheap, 
does  not  shrink  readily,  and  absorbs  odors  very 
slightly. 

As  a  protection  against  excessive  heat  the  color  of 
clothing  is  of  considerable  importance.  By  placing 
pieces  of  cloth  of  light  and  dark  shades  upon  snow  it 
is  found  that  the  snow  melts  more  readily  under  the 
dark  than  under  the  light  cloth.  From  this  we  infer 
that  light  colors,  such  as  yellow  or  white,  which  ab- 
sorb fewest  of  the  heat  rays  of  the  sun,  are  the  more 
suitable  colors  for  tropical  clothing.  The  presence  of 
cheap  aniline  dyes  in  underclothing  and  stockings 
will  occasionally  cause  considerable  irritation  to  the 
skin,  though  much  less  frequently  than  is  generally 
supposed.  By  observing  cleanliness  and  discarding 
the  offending  garment  relief  will  very  promptly  be 
afforded. 

Underclothing  should  be  washed  frequently,  de- 


76  THE  SKIN  AND  ITS  APPENDAGES. 

pending  on  the  amount  of  perspiration  of  the  wearer. 
It  should  be  aired  very  thoroughly  over  night,  and 
the  same  set  should  never  be  worn  both  day  and 
night.  Damp  underclothes  offer  a  most  excellent 
soil  for  the  growth  of  micro-organisms,  and  favor  the 
development  of  certain  parasitic  skin-diseases  which 
flourish  only  under  conditions  of  warmth  and  moist- 
ure. 

Rubber  or  mackintosh  clothing  is  very  useful  as 
a  protection  against  wind  as  well  as  rain,  and  is  suit- 
able for  persons  whose  occupation  requires  consider- 
able exposure  but  not  much  exercise,  as,  for  instance, 
coachmen  or  seamen.  For  active  occupations  it  is  to 
be  condemned.  Being  impermeable  to  air,  the  per- 
spiration cannot  evaporate  as  readily  as  it  does  when 
woollen  garments  are  worn.  There  has  lately  been 
introduced  a  form  of  waterproof  cloth  that  differs 
from  rubber  in  being  entirely  permeable  to  air. 
Overcoats  made  of  this  material  will  shed  rain  per- 
fectly, and,  unlike  a  mackintosh,  will  feel  perfectly 
comfortable  when  exercise  is  taken.  As  this  mate- 
rial allows  free  evaporation  of  the  perspiration  it 
forms  the  ideal  waterproof  garment. 

Shoes. — There  is  hardly  an  article  of  clothing  upon 
which  our  comfort  depends  to  so  large  an  extent  as 
upon  the  covering  of  the  feet.  It  seems  superfluous  to 
say  that  shoes  should  fit  the  feet  perfectly,  yet  owing 
to  the  demands  of  fashion  this  does  not  always  seem 
to  be  the  chief  consideration  in  purchasing  shoes.  If 
expense  need  not  be  considered,  boots  or  shoes  should 
be  made  to  order.  By  standing  in  the  stockings  a 
tracing  is  made  about  the  foot  and  from  this  the 
proper  last  is  constructed.      In  a  well-made  pair  of 


SHOES. 


77 


Fig.  14. — Normal  feet  (Whitman).  FiG.  15. — Proper  soles  for  normal 

feet  (Whitman). 

shoes  the  inner  sides  should  be  nearly  parallel  and 
not  diverge  greatly  when  the  wearer  stands  with  feet 


Fig.  16. — Deformed  feet 

(Whitman). 


Fig.  17. — Shoemakers'  soles 
(Whitman). 


together.     The  outer  side  of  the  shoe  should  have  a 
gentle  curve  inward,  and  the  toe  should  in  no  case  be 


78 


THE   SKIN  AND   ITS  APPENDAGES. 


pointed.  In  Fig.  14  is  shown  an  impression  made  by 
the  normal  foot.  To  provide  a  sensible  form  of  shoe 
for  a  foot  of  this  shape  it  does  not  seem  rational  to 
have  the  toe  narrow  and  pointed;  nor,  on  the  other 
hand,  perfectly  square  as  is  seen  in  some  of  the  so- 
called  common-sense  shoes.  The  sole  of  a  properly 
constructed  shoe  should  have  the  shape  shown  in 
Fig.  15.  In  Fig.  16  is  given  an  illustration  of  a 
foot  that  has  become  deformed  and  made  to  fit  a  shoe 
whose  shape  is  improper  and  unhygienic  (Fig.  17). 

It  is  most  essential  to  comfort  that  a  shoe  should  be 
sufficiently  long.  A  good  rule  to  follow  is  to  wear 
shoes  that  are  at  least  three-quarters  of  an  inch 
longer  than  the  foot.  By  observing  these  common- 
sense  ideas  many  troublesome  conditions,  such  as 
corns,  bunions,  and  others  more  serious,  may  be  pre- 
vented. 

The  soles  of  the  shoe  should  be  of  the  extension 
type  if  intended  for  hard  walking,   as  the  projecting 


Fig.  18.— The  rocker  sole 
(Whitman). 


Fig.  19.— The  flat  sole  (Whit- 
man). 


part  affords  considerable  protection  against  loose 
stones.  If  the  sole  is  flat,  a  much  better  support  is 
given  the  foot  than  in  the  usual  sole  that  turns  up 
from  the  ground  (see  Figs.  18  and  19).  The  leather 
should  be  moderately  thick  for  protection,  and  at  the 
same  time  pliable. 


SOCKS  AND  STOCKINGS— GARTERS.  79 

The  heels  should  always  be  broad  and  low.  The 
high  heels  so  frequently  worn  by  women  for  the 
purpose  of  increasing  their  height  and  lessening 
the  apparent  size  of  the  foot  are  harmful.  They  tend 
to  produce  weakness  of  the  arch  of  the  foot  through 
atrophy  of  the  plantar  ligaments.  lyow  shoes  are  a 
hygienic  form  of  footwear,  since  they  allow  excel- 
lent ventilation  of  the  foot,  and  are  especially  desir- 
able for  use  during  the  warmer  months. 

Patent  leather  shoes  are  not  advisable  for  con- 
tinued wear,  since,  being  impermeable  to  air,  they  do 
not  allow  proper  evaporation  of  the  perspiration  from 
the  feet.  However  uncomfortable  rubber  shoes  may 
feel,  they  are  probably  the  means  of  preventing 
many  colds  ;  they  should  never  be  worn  unnecessa- 
rily. For  those  who  have  to  do  considerable  walking 
in  wet  weather  and  cannot  conveniently  wear  rub- 
bers, hobnails  are  a  great  protection  to  the  soles  of  the 
shoes,  and  also  add  to  the  firmness  of  the  step. 

Socks  and  stockings  should  often  be  changed, 
the  frequency  depending  on  the  amount  of  perspira- 
tion of  the  wearer's  foot.  In  the  case  of  those  who 
suffer  from  excessive  perspiration  of  the  feet,  at  times 
of  a  bad  odor,  the  socks  or  stockings  should  be 
changed  daily.  The  feet  should  be  washed  and 
dried  without  friction,  and  over  the  feet  and  in  the 
fresh  socks  may  be  dusted  the  following  powder — 
salicylic  acid,  i  part  ;  starch,  4  parts. 

Garters. — Unfortunately,  ill-fitting  shoes  are  not 
the  only  portions  of  the  human  attire  that  bring  about 
evil  consequences  and  are  to  be  condemned.  Any 
article  of  clothing  which  unnaturally  constricts  a 
portion  of  the  body  is  harmful  and  unhygienic.    The 


8o  THE  SKIN  AND  ITS  APPENDAGES. 

circular  elastic  garter  acts  as  a  constant  tourniquet 
about  the  leg  and  interferes  with  the  circulation  of 
blood  in  the  veins.  These  will  tend  to  dilate  after 
awhile  and  become  tortuous,  giving  rise  to  the  con- 
dition known  as  varicose  veins.  The  dilated  veins 
generally  prove  to  be  sources  of  considerable  annoy- 
ance, and  at  times  of  danger.  Instead  of  using  circu- 
lar garters,  the  proper  plan  is  to  suspend  the  stockings 
from  some  part  of  the  underclothing. 

Corsets. — The  subject  of  improper  clothing  could 
not  well  be  passed  by  without  adding  a  few 
words  to  the  volume  of  protest  already  entered 
against  the  wearing  of  tight  corsets.  The  practice 
of  compressing  the  body  unnaturally  by  means  of 
various  kinds  of  stays  seems  to  continue  in  spite  of 
the  hostility  of  practically  all  physicians.  Constrict- 
ing the  waist  too  tightly  causes  a  change  in  position 
and  interferes  with  the  functions  of  many  of  the  in- 
ternal organs  (see  page  44).  It  prevents  the  proper 
muscular  development  of  women,  as  no  tightly-laced 
woman  can  indulge  in  any  vigorous  exercise.  Corsets 
greatly  interfere  with  the  fullest  attainment  of  health 
and  vigor.  When  tightly  laced  they  lessen  the  amount 
of  air  that  can  be  taken  into  the  lungs.  As  a  result 
the  blood  is  imperfectly  aerated,  deteriorates  in  quality, 
and  the  wearer  suffers  from  anemia. 

The  entire  list  of  injuries  attributed  to  wearing 
tight  corsets  is  a  formidable  one,  and  should  cause 
every  woman  to  think  before  continuing  the  prac- 
tice. Most  women  say  that  they  would  have  a  feel- 
ing of  utter  collapse  if  the  stays  were  to  be  laid 
aside.  This  is  due  to  the  imperfect  development  of 
muscles  that  are  not  called  into  play  when  stays  are 


BED-  Cf.  O  TJIING.  8  I 

worn,  but  whicli  should  be  strenj^tliened  by  exercise 
in  order  to  perform  their  natural  functions. 

A  certain  writer  has  expressed  opinions  about  stays 
that  have  given  great  consolation  to  women  who 
wear  them.  She  says  that  women  breathe  naturally 
with  the  chest,  especially  the  upper  portion,  and 
employ  abdominal  breathing  very  slightly,  so  that 
tight  lacing  which  does  not  interfere  with  chest 
breathing  is  hygienic  and  proper.  Opposed  to  this 
view,  some  experimenter  has  found  that  Indian  girls 
who  have  never  constricted  the  waist  by  stays  breathe 
with  the  diaphragm  as  naturally  as  do  men,  and  con- 
clude that  the  insufficient  method  of  breathing  with 
the  chest,  common  in  women,  is  itself  due  to  the 
habit  of  wearing  stays.  As  a  matter  of  fact,  no 
skilled  singing  teacher  would  ever  consent  to  allow 
his  pupils  to  sing  when  handicapped  by  a  tightly- 
laced  waist,  but  would  insist  upon  their  breathing  to 
their  utmost  capacity.  This  •  can  only  be  accom- 
plished when  both  chest  and  abdomen  are  free  and 
unhampered. 

Bed-clothing  should  not  be  unnecessarily  heavy. 
A  light  covering,  such  as  an  eiderdown  quilt,  will 
afford  more  warmth  than  a  blanket  of  greater  weight, 
owing  to  its  capacity  for  retaining  more  air  in  its 
meshes.  Similarly  two  coverings  will  be  warmer 
than  one  which  is  equal  to  both  in  thickness,  on 
account  of  the  layer  of  air  contained  between  them. 
Bed-clothing  should  be  aired  thorough!}'  every  morn- 
ing, the  windows  of  the  sleeping-room  being  opened 
for  this  purpose. 


82  THE  SKIN  AND  ITS  APPENDAGES. 

CARE  OF  THE  HAIR. 

A  fine  head  of  liair  is  a  possession  universally 
prized,  and  one  which  is  frequently  neglected  by  its 
owner  as  often  through  ignorance  as  through  care- 
lessness. In  the  preservation  of  the  hair  some  per- 
sons have  a  great  natural  advantage  over  others.  If 
there  is  an  inherited  tendency  to  baldness,  as  shown 
by  a  thin  and  poorly  nourished  scalp,  there  will  be 
greater  difficulty  in  preserving  the  hair  than  other- 
wise. 

The  scalp  is  comparable  to  the  soil.  Neither  hair 
nor  plants  will  grow  luxuriantly  if  the  quality  is  poor. 
A  scalp  which  is  favorable  to  the  growth  of  hair  is 
thick  and  pliable,  and  moves  freely  over  the  bones  of 
the  skull  beneath.  If  the  scalp  is  very  thin,  the 
blood-vessels  contained  will  be  few  in  number.  If  it 
is  drawn  tightly  over  the  skull,  it  will  tend  to  con- 
strict the  blood-vessels,  lessen  the  supply  of  blood  to 
the  scalp,  and  cause  atrophy  of  the  roots  of  the  hair 
from  pressure.  The  two  principal  causes  which 
bring  about  a  premature  thinning  of  the  hair  are  a 
deficient  circulation  of  the  blood  in  the  scalp  and  the 
constant  presence  of  dandruff. 

Dandruff  is  a  collection  of  epithelial  scales  mixed 
with  dried  sebaceous  matter,  and  is  the  forerunner  of 
premature  baldness  in  a  large  percentage  of  cases.  It 
will  be  present  to  a  greater  or  less  degree  in  many 
scalps  unless  it  is  constantly  guarded  against.  It  is 
highly  important  to  keep  the  scalp  perfectly  clean 
and  free  from  dandruff,  and  to  attain  this  end  daily 
brushing  of  the  hair  and  frequent  shampooing  are 
necessary. 


CARE    OF    '11 /E   HAfR.  83 

Hair-brushes. — Theliair  slionld  be  brushed  morn- 
ing and  night  for  several  minutes  until  there  is  a 
feeling  of  warmth  in  the  scalp  and  all  ])articles  of 
dandruff  are  removed.  For  an  adult  the  brush  should 
be  a  stiff  one,  with  the  little  tufts  of  bristles  widely 
separated  to  facilitate  cleaning.  For  children  and  for 
those  with  very  sensitive  scalps,  softer  brushes  must 
be  used.  Brushes  should  never  be  so  stiff  nor  the 
brushing  so  vigorous  as  to  produce  any  soreness  of 
the  scalp.  Brushes  should  be  frequently  washed  in 
water  containing  a  little  ammonia,  and  then  dried  in 
the  sun  with  the  bristles  down. 

Combs  are  chiefly  useful  for  disentangling  snarls 
and  dressing  the  hair,  and  may  be  employed  daily 
with  the  brush.  The  teeth  of  the  comb  should  be 
wide  apart,  have  blunt  ends,  and  be  free  from  any 
irregularities  which  might  tear  the  hair.  In  no  case 
should  the  old-fashioned  fine-toothed  comb  be  used, 
as  this  pulls  out  the  strong  hairs,  especially  if  the 
growth  is  luxuriant,  and  the  fine  points  may  produce 
disease  of  the  scalp  from  irritation. 

Many  persons  are  morbidly  afraid  that  any  consid- 
erable amount  of  brushing  and  combing  will  cause 
a  serious  loss  of  hair.  Its  effect,  however,  is  just  the 
opposite  and  increases  the  growth  of  hair  by  stimu- 
lating the  circulation  in  the  scalp  and  by  removing 
dandruff.  Brushing  removes  many  loose  hairs  which 
are  ready  to  fall,  but  their  place  will  soon  be  taken  by 
new  and  more  vigorous  ones.  The  groom  knows  by 
experience  that  the  only  way  to  keep  the  coat  of  his 
horse  thick  and  glossy  and  in  a  healthy  condition  is 
to  constantly  iise  the  currycomb  and  brush,  and  that 
he  is  not  likely  to  use  either  too  much. 


84  THE  SKIN  AND   ITS  APPENDAGES. 

Shampooing. — Many  persons  wlio  are  favored  by 
nature  with  a  luxuriant  growth  of  hair  and  who  per- 
haps consider  themselves  immune  to  baldness,  will 
grudgingly  give  any  time  to  the  care  of  the  hair  and 
consider  shampooing  especially  distasteful.  To  keep 
the  hair  clean  and  free  from  dandruff,  shampooing  at 
intervals  is  very  necessary. 

There  are  many  popular  fallacies  concerning  ques- 
tions of  physiology  and  hygiene,  and  some  ideas 
about  shampooing  of  the  scalp  are  no  exception  to  the 
rule.  Shampooing,  like  brushing,  also  removes  some 
loose  hairs,  but  by  cleansing  and  stimulating  the 
scalp  it  forms  a  most  important  means  of  preserving 
a  good  head  of  hair  or  aiding  to  restore  it  after  a  tem- 
porary falling.  The  frequency  of  shampooing  of  the 
scalp  depends  on  the  rapidity  with  which  dandruff 
accumulates,  and  to  some  extent  on  occupation  of  the 
individual.  For  some  persons,  washing  the  scalp 
once  a  month  will  be  found  sufficient  to  keep  it  in  a 
hygienic  condition.  Others,  and  especially  those 
whose  business  requires  much  travelling  or  exposure 
to  dust  and  dirt,  may  find  it  necessary  to  wash  the 
head  once  a  fortnight,  or  even  once  a  week.  There  is 
never  any  danger  of  shampooing  the  healthy  scalp 
too  frequently,  notwithstanding  the  opposite  state- 
ment so  frequently  made  by  some  hairdressers,  whose 
chief  stock  in  trade  is  some  ' '  tonic ' '  of  alleged 
miraculous  virtue.  When  the  hair  has  begun  to  fall 
out  prematurely,  due  to  long  neglect  or  following  an 
illness,  it  is  well  to  begin  shampooing  the  head  twice 
or  even  three  times  a  week,  and  to  gradually  lessen 
the  intervals  to  once  in  three  or  four  weeks. 

Not  only  are  some  afraid  that  the  shampoo  will 


SHAMPOOING.  85 

cause  considerable  loss  of  hair  through  the  friclioii 
employed,  but  they  fear  that  all  the  oil  in  the  scalp 
will  be  removed  and  great  damage  done  to  the  hair 
by  the  dryness  resulting.  Immediately  after  washing 
the  scalp,  especially  if  alcohol  be  used  in  addition  to 
the  soap,  the  scalp  will  certainly  feel  dry,  but  it  will 
soon  become  more  oily  than  usual  due  to  improve- 
ment in  circulation  and  consequent  stimulation  of  the 
oil-glands.  This  will  be  the  result  in  the  majority  of 
cases,  and  very  few  persons  will  suffer  from  dryness 
of  the  scalp  if  they  practice  shampooing  with  suffi- 
cient frequency.  Some  persons  actually  say  that 
after  the  shampoo  the  scalp  becomes  too  oily.  When 
the  scalp  fails  to  respond  to  the  mechanical  stimulus 
of  shampooing  by  producing  an  insufficient  amount 
of  sebaceous  matter,  then  it  is  well  to  rub  into  the 
scalp  some  form  of  grease  or  oil.  Nothing  answers 
the  purpose  better  than  pure  vaseline,  although  some 
barbers  prefer  to  use  olive  oil.  This  can  be  con- 
veniently applied  by  a  medicine-dropper,  after  making 
numerous  parts  in  the  hair.  The  use  of  soap  on  the 
hair  agitates  many  persons  who,  though  employing 
the  best  soap  in  cleaning  the  skin,  consider  that 
shampooing  is  a  dangerous  procedure  unless  the 
soap  used  is  recommended  by  physicians.  Any  good 
toilet  soap  upon  the  market  will  answer  the  purpose, 
and  more  harm  is  done  by  refraining  from  the  use  of 
the  shampoo  than  by  using  an  inferior  quality  of  soap 
on  the  hair. 

The  addition  of  alcohol  to  shampooing  liquids,  as 
in  the  tincture  of  green  soap  will  greatly  assist  the  thor- 
ough cleansing  of  the  scalp.  The  addition  of  an  egg 
to  the  shampoo  is  thought  by  mau}^  to  make  it  more 


86  THE   SKIN  AND  ITS  APPENDAGES. 

pleasant  and  effective.  As  the  egg  has  no  cleansing 
effect  its  use  is  largely  a  matter  of  taste.  There  is  no 
more  reason  for  its  employment  upon  the  scalp  than 
for  its  use  in  the  daily  washing  of  the  hands  and 
face. 

A  very  satisfactory  shampoo  liquid  is  found  in  the 
linamentum  saponis  mollis  of  the  Pharmacopeia, 
which  consists  of  50  parts  of  soft  soap,  2  parts  of  oil 
of  lavender,  and  33  parts  of  alcohol. 

In  the  operation  of  shampooingany  ordinary  good 
toilet  soap  may  be  selected.  A  lather  is  then  formed 
and  rubbed  vigorously  into  the  scalp  with  the  finger 
tips  or  a  stiff  brush,  a  nail  brush  being  very  conve- 
nient for  the  purpose.  The  lather  is  best  removed  by 
a  warm-water  douche,  always  ending  the  process  with 
cold  water  to  lessen  the  danger  of  contracting  a  cold. 
The  hair  is  then  to  be  dried  as  thoroughly  as  possible 
with  towels,  and  to  complete  the  drying  it  is  well  to 
remain  for  a  while  in  the  sun  or  near  an  open  fire  or 
radiator. 

Head-gear. — While  many  persons  naturally  possess 
a  thin  head  of  hair  and  a  poor  circulation,  they  are 
handicapped  still  further  by  various  causes  that  tend 
to  lesson  the  circulation  in  the  scalp.  One  of  these 
causes  is  the  wearing  of  hats.  The  hats  worn  by  men 
at  the  present  time,  especially  the  Derby  and  silk  hat, 
allow  very  little  ventilation,  prevent  the  access  of 
sunlight  as  well  as  air,  and  do  not  permit  the  proper 
evaporation  of  the  perspiration.  The  tight-fitting 
brim  also  constricts  the  blood-vessels  and  hinders  the 
circulation.  Women's  hats  have  no  tight  brim,  allow 
free  ventilation,  and,  unless  very  heavy,  are  seldom 
objectionable  in  this   respect.     The  interesting  and 


MASSAGE    OF   Till':   SCAIJ\  8/ 

oft-repeated  argiiinents  against  the  wearing  of  hats 
may  here  be  cited.  Savages  who  go  bareheaded  do 
not  suffer  from  baldness,  and  tlic  same  immunity 
to  early  falling  of  the  hair  is  said  to  be  the  gocxl  for- 
tune of  the  lads  of  the  "Blue-Coat  vSchool "  in 
London.  These  boys  never  wear  any  hats,  however 
stormy  the  weather  may  be  nor  how  low  the  ther- 
mometer may  descend. 

As  the  hats  of  the  present  day  seem  to  be  necessary 
evils,  the  only  practical  advice  that  may  be  given  is 
that  they  should  not  be  worn  unnecessarily,  especially 
when  the  head  is  perspiring,  and  that  they  should 
not  be  jammed  on  the  head  with  such  firmness  as  to 
interfere  with  the  circulation  of  the  scalp.  The  fact 
that  women  are  more  free  from  baldness  than  men 
may  be  due  in  a  slight  degree  to  their  wearing  a  more 
hygienic  form  of  head-gear,  but  undoubtedly  the  chief 
cause  lies  in  their  possession  of  a  thick  scalp  and  an 
underlying  cushion  of  fat,  which  is  naturally  better 
adapted  to  support  a  good  growth  of  hair. 

Some  physicians  think  that  the  amount  of  brain- 
work  done  may  be  a  factor  in  bringing  on  premature 
baldness,  but  this  has  not  been  definitely  proven. 

The  answer  to  the  question  as  to  what  can  be  done 
to  improve  the  circulation  of  the  scalp  and  the 
growth  of  the  hair  is,  briefly — mechanical  stimula- 
tion. This  may  be  practised  through  shampooing, 
massage,  and  the  local  application  of  electricity. 
Shampooing  has  been  considered,  and  its  thorough 
and  frequent  practice  cannot  be  too  strongh'  urged. 

Massage  of  the  Scalp. — Vigorous  daily  massage, 
if  continued  for  a  considerable  time,  will  tend  to  im- 
prove the  circulation  and  to  increase  the  growth  of 


88  THE  SKIN  AND   ITS  APPENDAGES. 

hair.  If  the  scalp  is  pale  and  thin,  it  is  well  to  com- 
bine a  few  minutes  of  massage  by  the  finger-tips 
with  the  daily  morning  and  night  brushing.  A 
variety  of  motions  may  be  practised,  such  as  moving 
the  fingers  over  all  parts  of  scalp,  and  then  placing 
them  firmly  on  the  scalp  and  moving  the  scalp  itself 
over  the  bones  beneath. 

Electricity  acts  merely  as  a  local  stimulant  to  the 
circulation,  and  is  best  used  in  the  form  of  galvan- 
ism, A  wire-brush  electrode  is  attached  to  the 
negative  pole  of  the  galvanic  battery,  and  applied  to 
the  scalp  through  the  hair  until  the  former  becomes 
well  reddened. 

Cutting  the  Hair. — Many  persons  entertain  the 
false  idea  that  cutting  the  hair  increases  its  thick- 
ness. While  it  may  aid  to  some  extent  the  rapidity 
of  growth,  cutting  certainly  does  not  increase  the 
number  of  hairs.  To  keep  the  hair  short  in  chil- 
dren up  to  the  age  of  eight  or  nine  years  is  generally 
deemed  sensible  and  hygienic.  Its  good  effect  is 
mostly  due  to  the  easier  access  of  air  and  sunlight  to 
the  scalp  and  to  the  greater  ease  with  which  the  head 
can  be  kept  clean,  although  some  think  that  if  the 
hair  of  a  growing  child  is  kept  short  there  will  be 
less  of  a  tax  upon  its  strength  and  vitality. 

The  opinion  seems  to  be  pretty  general  that  shaving 
with  a  sharp  razor  will  produce  a  thicker  and  firmer 
growth  of  hair,  although  one  recent  writer  on  hy- 
giene claims  that  .shaving  actually  has  a  depilatory 
effect.  In  the  process  of  shaving,  the  roots  of  the 
hairs  are  stimulated  to  a  slight  degree,  and  a  coarser 
and  thicker  growth  upon  the  face  of  a  young  man 
doubtless  results  in  due  time  ;  but  time  rather  than 


HAIR  RESTOKKKS   OR    IJAJR    TONJCS—J'OMADES.    89 

shaving  is  responsible  for  the  change.  The  experiment 
occasionally  tried  by  enthusiasts  of  shaving  the  head  in 
the  hope  of  obtaining  abetter  growth  of  hair  is  never 
productive  of  any  brilliant  result,  and  may  be  con- 
sidered as  absurd  and  useless. 

In  dressing-  the  hair  it  is  important  to  make  no 
violent  traction  upon  the  roots,  as  this  has  a  ten- 
dency to  loosen  and  cause  a  falling  of  the  hair. 
There  should  be  no  twists  or  knots  which  produce  feel- 
ings of  discomfort  for  such  are  certain  to  prove  in- 
jurious. There  is  no  great  objection  to  curling-  the 
hair  if  it  is  not  done  with  too  much  vigor.  Curl 
papers,  if  not  put  on  so  tightly  as  to  pull  on  the  roots 
of  the  hair,  are  not  likely  to  do  harm.  Curling  irons, 
however,  are  often  overheated  and  make  the  hair  un- 
naturally dry  and  brittle. 

A  very  absurd  idea  that  pervades  the  mind  of  the 
average  "  tonsorial  artist"  is  that  singeing  the  hair 
will  tend  to  preserv-e  it  and  to  stimulate  its  growth. 
There  is  no  truth  in  the  barber's  assertion  that  the 
hair  is  a  hollow  tube  which  will  allow  the  escape  of 
oil,  and  that  if  the  ends  can  only  be  sealed  by  singe- 
ing much  benefit  will  result. 

Hair  restorers  or  hair  tonics  are  fully  as  useless 
as  singeing.  These  preparations,  which  are  wadely 
advertised,  fail  utterly  to  accomplish  the  purpose  for 
which  they  are  employed.  Shampooing,  brushing, 
massage  of  the  scalp,  and  attention  to  the  general 
health,  and  not  the  use  of  a  hair  tonic,  are  the  only 
means  of  preserving  a  good  head  of  hair  and  aiding 
its  restoration  after  falling. 

Pomades  are  mentioned  only  to  say  that  their  use 
in  general  is  considered   unnecessary,   while  to  most 


90  THE  SKIN  AND  ITS  APPENDAGES. 

people  they  seem  uncleanly  and  disagreeable.  A 
generation  ago  some  oily  dressing  for  the  hair 
was  universally  used,  largely  because  it  was  the 
fashion.  Bear's  grease  was  often  used  as  an  ingre- 
dient of  the  pomade,  in  hopes  that  some  hair-restor- 
ing properties  might  be  possessed  by  the  fat  of  an 
animal  as  naturally  hairy  as  the  bear. 

Many  young  men  indulge  in  the  habit  of  fre- 
quently wetting  the  hair  in  order  to  make  it  set 
smoothly.  In  addition  to  producing  a  doubtful 
esthetic  effect,  this  practice  is  harmful  by  tending 
to  cause  decomposition  of  the  roots  of  the  hair.  As 
has  been  stated,  there  is  no  harm  in  washing  the  hair 
frequently  if  it  is  subsequently  dried  with  towels. 

Removal  of  Superfluous  Hair. — The  use  of  de- 
pilatory pastes  or  substances  to  remove  superfluous 
hairs  is  not  recommended,  except  upon  the  advice  of 
a  physician.  These  pastes  will  often  remove  a 
downy  growth  of  hair,  but  cannot  remove  large  stiff 
hairs  without  doing  too  much  damage  to  the  skin  to 
warrant  their  employment.  For  removing  large 
hairs,  the  only  satisfactory  method  is  the  slow  but  sure 
one  by  electrolysis.  By  this  method  an  experienced 
operator  can  remove  any  number  of  large  hairs  per- 
manently without  leaving  any  scars  or  causing  much 
pain. 

Gray  Hair. — An  eminent  dermatologist  has  re- 
marked that  the  only  sensible  thing  to  do  for  gray 
hair  is  to  admire  it.  While  gray  hair  undoubtedly 
improves  the  looks  of  some  people  and  is  welcomed 
by  them,  it  is  to  others  a  source  of  considerable  an- 
noyance. In  the  rare  cases  of  sudden  blanching  of 
the  hair,  such  as  sometimes  follows  profound  mental 


CARE    OF   THE   BEARD.  9 1 

disturbance,  a  return  of  the  former  color  is  a  possi- 
bility, but  even  this  could  not  probably  be  aided  by 
any  efforts  of  the  physician.  Nothing  can  really  be 
done  to  prevent  the  hair  turning  gray. 

Dyeing  the  hair  is  an  exhibition  of  poor  taste,  and 
is  really  only  excusable  in  the  case  of  young  persons 
whose  hair  has  turned  gray  at  an  unusually  early 
age.  Many  of  the  dyes  for  coloring  the  hair  black 
contain  lead,  and  on  this  account  should  be  avoided, 
as  cases  of  lead-poisoning  from  the  use  of  hair-dyes 
undoubtedly  have  occurred. 

Before  the  application  of  any  hair-dye  the  head 
should  be  thoroughly  shampooed  and  then  dried.  The 
dye  is  most  conveniently  applied  to  the  hair  by  a 
tooth-brush,  avoiding  contact  as  far  as  possible  with 
the  scalp. 

Leonard  recommends  the  following  harmless  hair- 
d)^e  for  producing  a  black  color. 

B. — Bismuth  citrate,  i  ounce  ; 

Rose  water,  2  ounces  ; 

Distilled  water,  •   2  ounces  ; 

Alcohol,  Yz  ounce  ; 

Ammonia  water,  a  few  drops. 

To  be  applied  in  the  morning. 

R. — Sodium  hyposulphite,  ij^  ounces  ; 

Distilled  water,  4  ounces. 

To  be  applied  at  night. 

To  obtain  a  brown  color  a  mixture  of  pyrogallic 
acid  and  rose  water  may  be  used 

Care  of  the  Beard. — An  equal  amount  of  care 
should  be  bestowed  upon  the  cleanliness  of  the  beard 
and  mustache,  as  is  shown  in  the  case  of  the  scalp. 


92  THE   SKIN  AND  ITS  APPENDAGES. 

The  frequent  ablutions  of  the  face  during  the  day 
should  include  both  beard  and  mustache.  To  give 
softness  and  lustre  to  the  mustache,  preparations 
known  as  brilliantines  may  be  employed  without 
danger  of  a  harmful  effect.  A  suitable  formula  for 
such  a  preparation  consists  of  glycerin,  castor  oil,  and 
alcohol  in  the  proportions  of  one,  two,  and  three  re- 
spectively, to  which  a  proper  amount  of  perfume  may 
be  added. 

In  regard  to  shaving,  it  may  be  said  that  it  is  always 
a  good  plan  for  a  man  to  practise  shaving  himself  and 
so  avoid  any  possible  danger  of  infection  from  the 
barber-shop.  In  these  establishments  a  number  of 
diseases  may  be  contracted,  notably  ringworm.  This 
affection,  so  obstinate  when  attacking  the  hairy  por- 
tions of  the  body,  is  usually  acquired  from  the  use  of 
a  damp  towel,  less  often  from  the  shaving-brush,  the 
"clipper,"  or  the  hands  of  the  barber.  The  razor  is 
not  at  all  likely  to  be  the  cause  of  infection.  The 
damp  towel  offers  a  most  excellent  medium  for  the 
growth  of  the  ringworm  parasite,  as  this  fungus,  like 
ordinary  mould,  requires  moisture  for  its  development. 
If  a  barber-shop  is  to  be  patronized  regularly,  the 
customer  should  have  a  private  cup,  shaving-brush, 
and  razor.  If,  in  addition,  the  towels  to  be  used  are 
perfectly  clean  and  dry,  and  the  barber  washes  his 
hands  thoroughly  after  shaving  each  customer,  there 
will  be  still  less  danger  of  contracting  ringworm  and 
other  infectious  diseases. 

Care  of  the  Nails. — The  proper  care  of  the  nails 
depends  upon  the  observance  of  a  very  few  and  sim- 
ple rules.  The  portion  of  skin  overhanging  the  root 
of  the  nail  tends  to  encroach  too  far  over  the  lunula, 


CAI^E    OF   THE   NAILS.  93 

and  is  likely  to  become  torn  and  ragged,  giving  rise 
to  so-called  "  hangnails."  These  offer  little  open- 
ings throngh  which  infections  matter  may  enter  and 
do  a  good  deal  of  damage,  and  it  is  possible  for  blood- 
poisoning  to  result  from  infection  through  one  of  these 
apparently  insignificant  lacerations.  The  epidermis 
overhanging  the  root  of  the  nail  should  be  pressed 
back  once  or  twice  a  week  with  some  convenient  in- 
strument. For  cleaning  the  nails,  nothing  but  soap, 
warm  water,  and  the  nail-brush  should  be  employed. 
The  penknife  should  not  be  used  in  place  of  the  nail- 
cleaner,  as  it  scratches  the  under  surface  of  the  nail 
and  makes  a  place  for  the  lodgement  of  dirt.  The 
surface  of  the  nail  should  never  be  scraped. 

A  word  of  advice  may  be  given  in  regard  to  cut- 
ting tine  nails,  for  it  seems  that  the  proper  method  is 
not  universally  known.  The  finger-nails  are  most 
conveniently  cut  in  a  curved  direction,  or  they  may 
be  filed  if  this  slower  method  is  preferred,  A  pair 
of  curved  scissors  is  very  convenient  for  cutting  the 
finger-nails,  but  should  not  be  used  for  the  toe-nails, 
as  these  are  always  to  be  cut  straight  across.  If,  in 
addition  to  the  proper  selection  of  shoes,  this  last  pre- 
caution is  observed,  a  great  deal  of  trouble  and  dis- 
comfort may  be  avoided. 

For  removing  stains  from  the  nails  a  solution  of 
acetic  acid  and  rose  water,  one  part  of  the  former  to 
sixteen  parts  of  the  latter,  may  be  employed.  Oxalic 
acid  is  perhaps  more  efficient  for  accomplishing  this 
purpose,  but  its  use  is  not  desirable,  owing  to  its 
poisonous  qualities. 


HYGIENE  OF  THE  VOCAL  AND  RESPIRATORY 
APPARATUS. 

By  E.  FLETCHER  INGALS,  M.  D., 

OF   CHICAGO, 

Professor  of  Laryngology  and  Diseases  of  the  Chest  in  the  Rush  Medical 

College  ;   Professor  of  Laryngology  and  Rhinology 

in  the  Chicago  Polyclinic. 


THE  NOSE. 

The  nose  is  described  as  consisting  of  an  outer,  or 
facial,  and  an  inner  portion  ;  the  latter  lying  within 
the  skull. 

The  outer  nose  has  a  bony  framework  in  its  upper 
portion,  consisting  of  the  nasal  bones  and  nasal  proc- 
esses of  the  upper  jaw.  The  lower  half  of  the  outer 
nose  is  made  of  flexible  cartilages,  supported  in  the 
center  by  the  septum,  or  dividing  wall  of  the  nostrils 
(Figs.  20,  21).  The  external  nose  has  muscles  of 
great  importance  in  facial  expression,  and  capable 
of  dilating  the  nostrils  during  inspiration. 

The  inner  nose  consists  of  two  lofty  air-passages, 
extending  back  into  the  skull  as  far  as  the  posterior 
end  of  the  hard  palate,  or  roof  of  the  mouth.  Here 
the  nostrils  end  in  a  roomy  chamber  called  the  naso- 
pharynx. 

The  inner  wall  of  each  nasal  passage,  or  naris,  as 
it  is  called,  is  formed  by  the  division  of  the  nostrils, 
or  septum  (Fig.  21).  This  is  composed  in  its  back 
94 


THE   NOSE. 


95 


and  upper  parts  of  two  bones,  the  vomer,  or  plough- 
share, below,  and  a  thin  plate  of  bone  above,  called 


upper  lateral, 
cartilage 

Lower  lateral. 
cartiUii^e 


Sesamoid  bones 
Cell  tissue 


Fig.  20. — Lateral  cartilages  of  tlie  nose. 

the  perpendicular  plate  of  the  ethmoid  bone.     These 
two  bones  join  behind  to  form  a  solid  wall,  but  spread- 


Horizontal 
plate  of  ctJtinoid 


Fc  i/>endic!ila  r 
/•late  of 
ethmoid 


Palatal 


I.oii'cr  lateral 
cartilage 

Siif-erior 
maxillary 


Fig.  21.— Cartilage  and  bones  of  the  septum  of  the  nose. 


ing  in  front  include,  like  a  V,  the  front  or  cartilagi- 
nous part  of  the  septum,  which  fortunately  is  very  flex- 


96  VOCAL   AND   RESPIRATORY  APPARATUS. 

ible  ;  because  if  it  were  of  bone,  fractures  of  this  part 
of  the  nose  would  occur  very  frequently. 

The  outer  wall  of  the  nose  is  made  of  a  compli- 
cated bony  framework,  supporting  three  ledges  or 
shell-like  projections  into  the  nasal  cavities,  called  the 
turbinated  bodies.  These  bodies  consist  of  thin 
bone  covered  with  mucous  membrane,  containing  a 
sponge-like  network  of  blood-vessels,  forming  what 
is  called  erectile  tissue.  There  are  three  turbinated 
bodies  in  each  nostril,  called  the  lower,  the  middle,  and 


,  4 

Fig.  22. — Anterior  nares,   show  ins;  white   deposit  of  inspired  magnesium- 
powder  upon  the  septum  and  middle  turbinals  only. 

the  upper.  The  lower  and  the  middle  extend  the  whole 
length  of  the  nasal  cavity;  the  upper  along  the  posterior 
half  only.  Underneath  the  lower  turbinate  we  have 
the  opening  of  the  tube,  or  duct,  conducting  the  tears 
from  the  eye  to  the  nose  ;  under  the  middle  turbinated 
body  we  have  the  opening  to  a  thin- walled  cavity, 
which  hollows  out  the  upper  jaw,  and  is  called  the 
antrum  of  Highmore.  This  cavity  lies  immediately 
external  to  the  nostril. 

Accessory  Sinuses. — There  are  other  bony  cavities 
connecting  with  the  nose  in  this  location,  two  in  the 
forehead,  or  frontal  bone,  and  a  large  number  of  cells 
in  a  very  thin  bone  at  the  top  of  the  nose,  called  the 


77//',    MUCOUS   MKMJiRANE.  97 

etliuioid  bone.  These  cliainbeis  in  tlie  bones  of  tlie 
skull  all  contain  air. 

The  roof  of  the  nose  is  formed  by  the  nasal  bones 
in  front  ;  behind  this  by  a  plate  of  thin  bone  separ- 
ating the  nasal  cavity  from  the  brain.  This  plate  of 
bone  contains  many  sieve-like  holes,  which  give  pas- 
sage to  the  filaments  of  the  nerve  of  smell,  and  is 
called  the  cribiform  plate  of  the  ethmoid  bone.  A 
hollow  bone  back  of  this  completes  the  roof  of  the 
nose  ;   it  is  called  the  body  of  the  sphenoid  bone. 

The  floor  of  the  nasal  cavity  is  formed  by  the 
hard  palate,  a  thick,  massive  plate  of  bone  forming 
also  the  roof  of  the  mouth. 

The  mucous  membrane  of  the  nose  is  very  sensi- 
tive, having  many  nerves  of  sensation  from  the  fifth 
pair  of  nerves  besides  the  special  nerves  of  smell, 
which  are  found  only  along  the  space  between  middle 
turbinated  body  and  the  septum,  in  the  so-called 
olfactory  region. 

A  single  layer  of  minute,  microscopic  epithelial 
cells  covers  the  surface  of  the  nasal  mucous  mem- 
brane, like  pavement  blocks,  each  cell  having  hair- 
like processes  on  its  free  surface,  called  cilise.  Nu- 
merous little  tubes,  called  mucous  glands,  keep  the 
mucous  membrane  lubricated  with  mucus. 

The  best  known  of  the  functions  of  the  nose  is  the 
sense  of  smell  ;  but  the  other  functions  are  more 
important  to  the  health  of  the  individual.  The  many 
folds  and  narrow  passages  of  the  nasal  surface  warm 
the  air  as  it  passes  over  them,  at  the  same  time  sup- 
plying it  with  moisture  to  the  extent  of  two-thirds 
saturation.  The  moist  mucous  membrane  of  the 
nose  also  catches  almost  all  of  the  dust  that  escapes 

7 


98  VOCAL   AND   RESPIRATORY  APPARATUS. 

the  many  hairs,  or  vibrissse,  as  they  are  called, 
which  are  placed  at  the  entrance  to  the  nostrils. 
Whatever  dust  lodges  on  the  mucous  surface  is  pushed 
toward  the  outer  orifice  by  the  minute  ciliae,  which 
are  in  constant  outward  motion.  With  the  dust,  of 
course,  any  microbes  entering  the  nose  are  also 
expelled.  In  addition  to  this  mechanic  expulsion, 
however,  the  nose  probably  possesses  the  power  of 
destroying  the  bacteria  by  means  of  its  mucus,  which 
is  germicidal,  so  that  only  a  very  short  distance  within 
the  nostrils  the  mucous  membrane  is  found  compara- 
tively free  from  microbes. 

Obstruction  in  the  Nasal  Passages. — To  keep  the 
nose  and  the  air-passages  below  it  in  a  healthy  state 
the  nostrils  must  be  open  for  the  passage  of  air.  The 
commonest  cause  of  stopping  up  of  the  nose  in  chil- 
dren is  enlargement  by  adenoid  growth  of  a  structure 
called  the  pharyngeal  or  Luschka's  tonsil,  or  the 
third  tonsil.  This  is  placed  behind  the  posterior  open- 
ings of  the  nose,  and  when  enlarged  enough,  may  en- 
tirely obstruct  breathing  through  it.  Practically  all 
mouth-breathing  children  have  this  form  of  obstruc- 
tion, the  external  nasal  passages  being  open.  If  this 
form  of  nasal  blocking  is  allowed  to  persist,  it  has  a 
very  deleterious  effect  on  the  development  of  the  inner 
nose,  which  from  lack  of  use  is  retarded  in  its  growth. 
In  such  cases  the  nasal  passages  at  the  beginning  of 
adult  life  are  as  small  as  those  of  a  child,  while  the 
upper  jaw  is  narrow,  producing  an  ugly  protrusion  of 
the  front  teeth  and  a  characteristic  stupid  expression. 

In  adults,  nasal  obstructions  are  often  due  to 
deformities  of  the  septum,  which  is  either  much 
bent  to  one  side  or  thickened  in  such  a  way  as  to  close 


MO  [77  'II-  BREA I I/ING.  99 

up  one  nostril  permanently.  (3ther  frequent  causes 
of  stoppages  of  the  nose  of  a  lasting  character  are 
mucous  growths  called  polyps.  The  most  common 
source  of  nasal  occlusion  in  grown  persons  is  swell- 
ing of  the  nasal  mucous  membrane. 

Mouth -breathing,  with  its  attendant  evils,  is  the 
result  of  these  obstructions  to  the  free  passage  of  air 
through  the  nose.  Mouth-breathing  .allows  the  en- 
trance of  dust  and  microbes  directly  to  the  lower  air- 
passages,  larynx,  trachea,  and  lungs  ;  whereas  in 
breathing  through  the  nose  most  of  these  particles  are 
lodged  on  the  nasal  mucous  membrane  and  returned 
to  the  outer  world  in  the  ways  mentioned.  The 
bronchi  and  trachea  have  ciliated  epithelium  as  well 
as  the  nose,  and  although  this  epithelium,  by  means 
of  its  waving,  hair-like  processes,  is  capable  of  expel- 
ling many  of  the  minute  foreign  bodies  that  enter  the 
lungs,  still  some  reach  the  air-cells  even  under  ordi- 
nary conditions  when  breathing  is  carried  on  with  the 
mouth  "closed,  while  mouth-breathing  adds  enor- 
mously to  their  number.  In  this  way  the  microbes 
of  tuberculosis,  pneumonia,  bronchitis,  influenza,  etc. 
penetrate  the  lungs  more  readily  than  in  nose-breath- 
ing. This  is  especially  true  of  the  rapid  and  forced 
breathing  accompanying  violent  exertion.  Through 
the  open  mouth  diphtheria  germs  reach  the  larynx  or 
tonsils  directly. 

Closure  of  one  nostril,  common  in  adults,  com- 
pels the  sufferer  to  try  heroically  to  breathe  through 
the  other  nostril,  with  consequent  rarefaction  of 
the  air  in  the  free  nasal  passage  and  the  pharynx, 
thus  by  suction  overfilling  the  blood-vessels  and  pre- 
disposing to  catarrhal  diseases.     In  singers  the  effect 


lOO  VOCAL   AND   RESPIRATORY  APPARATUS. 

of  nasal  stoppage  is  to  place  undue  strain  on  the  voice 
by  trying  to  overcome  the  lack  of  resonance  due  to 
the  obstructed  nose. 

It  is  well  known  to  long-distance  runners  that  the 
breath  gives  out  very  soon  if  mouth-breathing  is 
used,  while  breathing  through  the  nose  is  soon  fol- 
lowed by  what  is  called  "second  wind,"  during 
which  respiration  becomes  easy  again.  Second  wind 
is  partly  due  to  a  dilatation  of  the  blood-vessels,  mak- 
ing the  blood-pressure  lower  and  the  heart's  action 
easier.  It  is  also  in  part  due  to  the  fact  that  in 
breathing  through  the  comparatively  narrow  nasal 
orifice  the  air  enters  the  thorax  with  more  difficulty 
than  through  the  mouth;  this  increases  the  negative 
pressure  within  the  chest,  causes  the  respirations  to 
be  long  and  deep,  and  so  gives  the  thorax  an  oppor- 
tunity to  pump  blood  as  well  as  air  into  its  cavity, 
thus  aiding  the  heart  in  its  work.  So  deep  breathing 
through  the  nose  during  exertion  tends  to  lessen  the 
heart-strain  of  cycling,  running,  boxing,  or  other 
sports  and  exercises. 

The  foregoing  statements  sufficiently  prove  how 
indispensable  to  healthy  respiratory  organs  is  an  un- 
obstructed nose. 

Causes  of  Nasal  Disease. — A  healthy  nose  needs 
no  care  by  means  of  sprays,  nasal  douches,  and  the 
like.  In  fact,  the  care  of  the  nasal  passages  involves 
chiefly  a  knowledge  of  the  causes  predisposing  to 
nasal  disease,  and  as  far  as  possible  the  avoidance  of 
these  causes.  There  are,  however,  classes  of  nasal 
affections,  such  as  malignant  growths,  bony  tumors, 
etc.,  which  are  not  preventable,  but  much  can  be 
done  to  limit  the  occurrence  of  the  ordinary  catarrhal 


TO  AVOID   CATCHING    COLD.  10 1 

affections  of  the  nose  which  lead  np  to  other  morbid 
conditions,  such  as  polypi  or  suppuration  of  the  air- 
chambers  about  the  nose  called  the  sinuses. 

First  among  the  causes  of  catarrhal  nasal  affections 
is  exposure  to  cold,  especially  of  those  portions  of 
the  body  ordinarily  protected  by  clothing.  This 
occurs  especially  during  high  winds  or  chilly  and 
damp  weather,  as  a  result  of  wetting  of  the  garments, 
and  from  insufficient  covering  at  night.  It  is  pro- 
longed exposure  in  moderately  low  temperatures  that 
is  dangerous,  rather  than  a  short  subjection  of  the 
body  to  a  sudden  cold  shock.  A  cold  douche  or 
plunge  is  followed  by  vigorous  contraction  of  the 
smooth  muscle-fibers  of  the  skin,  driving  the  blood 
from  the  surface,  while  in  prolonged  exposure  to 
slight  cold  there  is  no  such  reaction  of  the  skin  and  a 
a  large  amount  of  blood  is  cooled  slowly.  This  is  es- 
pecially true  of  those  who  have  made  themselves  non- 
resistant  and  "soft"  by  excessive  clothing  or  con- 
tinued indoor  life.  Contraction  of  the  muscles  and 
vessels  of  the  skin  does  not  take  place  as  readily  in 
such  persons  as  in  hardy  ones  used  to  exposure  and 
outdoor  existence.  Cold  as  a  cause, of  catarrhal  nasal 
affections  does  not  seem  operative  in  very  pure  air,  as 
is  the  experience  in  Arctic  exploring  expeditions,  so 
that  the  congestion  of  the  mucous  membrane  caused 
by  cold  appears  to  need  in  addition  microbic  infection 
to  produce  the  common  "colds  in  the  head." 

To  avoid  catching  cold  it  is  needful  to  make  the 
body  resistant  to  the  influence  of  cold.  The  cold 
shower-bath  is  of  great  value  for  this  purpose.  It 
may  be  used  every  morning  or  evening  for  from 
one  to   two   minutes.       The   water   should   be    cold 


I02  VOCAL   AND   RESPIRATORY  APPARATUS. 

enough  to  produce  a  decided  reaction  with  the  ap- 
pearance of  ' '  goose-flesh' '  pimples  on  the  skin.  As 
the  body-temperature  and  vigor  are  lowest  in  the 
morning,  the  evening  shower  is  preferable  for  delicate 
people.  Over-heated  rooms  and  too  much  clothing 
are  to  be  avoided.  It  is  well  to  see  that  the  sleeping- 
room  does  not  cool  down  slowly  over  night,  but  that  it 
is  properly  cooled  at  bedtime. 

As  is  true  of  most  other  ailments,  the  avoidance  of 
nasal  catarrh  involves  also  the  keeping  of  the  body 
in  its  best  physical  condition,  when  the  nasal  pas- 
sages will  resist  irritants  that  in  depreciated  health 
they  cannot  withstand.  This  is  especially  so  of  the 
inhalation  of  irritants,  such  as  dust  or  germs,  which 
of  themselves  are  not  likely  to  cause  nasal  catarrh  in 
healthy  persons. 

Although  the  healthy  nose  can  dispose  of  dust  and 
microbes  so  well,  as  soon  as  its  mucous  membrane  is 
swollen  and  inflamed  in  consequence  of  catarrhal 
states  it  becomes  liable  to  germ  infection,  so  that  in 
the  last  stages  of  acute  catarrh  of  the  nose,  and  in 
many  cases  of  the  same  affection  of  a  chronic  order, 
we  have  a  purulent  secretion  on  account  of  pus-pro- 
ducing germs  present  in  the  nose. 

The  bacilli  of  diphtheria,  tuberculosis,  influenza 
and  glanders,  staphylococci  and  streptococci,  and  the 
contagion  of  measles  and  of  scarlet  fever  are  all 
liable  to  infect  the  nose,  especially  when  the  soil  is 
prepared  by  a  nasal  catarrh. 

It  is  possible  to  avoid  dust-inhalation  up  to  only 
a  certain  limit;  but  the  amount  of  dust  in  households 
should  be  reduced  to  at  least  a  minimum.  The 
greatest    dust-catcher    is    carpet,    but   curtains   and 


THE   DRY  AIR    OF  IIKATKI)   HOUSES.  I03 

drapery  hold  large  amounts.  It  is  in  sweeping  and 
dusting  these  articles  that  dust  is  distributed  over 
the  rooms  and  remains  in  the  air  for  hours.  It  is 
known  that  the  air  of  rooms  contains  many  more 
microbes  than  that  of  the  city  streets.  Those  who 
have  dusty  occupations  are  often  told  to  use  a  respir- 
ator, but  these  contrivances  are  generally  so  dis- 
figuring that  few  can  be  induced  to  wear  them,  so 
that  in  this  class  there  will  be  many  victims  of 
unhealthy  respiratory  conditions  as  long  as  employers 
do  not  supply  pure  air  to  their  establishments. 

The  dry  air  of  heated  houses  in  winter  is  unfav- 
orable to  healthy  conditions  in  the  nose.  The  se- 
cretions become  scanty,  and  the  mucous  membrane 
becomes  dry,  preventing  the  elimination  of  dust  iii 
the  normal  manner.  The  mucus  forms  adherent 
crusts  which  are  liable  to  crack  and  be  torn  off,  in- 
juring the  epithelial  coating  of  the  underlying  mem- 
brane, and  so  opening  the  way  to  germ  infection. 
This  is  especially  the  case  if  a  slight  catarrhal  condi- 
tion already  exists.  Erysipelas  is  sometimes  caused 
in  this  way,  the  microbe  of  this  disease  entering  the 
fissures  and  denuded  places  about  the  nostrils. 

It  should  be  regarded  almost  as  important  to  supply 
moisture  to  the  air  of  a  house  in  winter  as  to  supply 
heat,  and  until  architects  appreciate  this  fact,  most 
persons  will  suffer  rather  than  use  such  troublesome 
preventive  measures  as  hanging  moist  cloths  in  front 
of  the  radiators,  etc. 

An  atomizer  containing  a  saturated  solution  of 
boric  acid  is  a  useful  article  in  the  care  of  the  nose 
when  the  evil  conditions — dust-breathing  and  dry 
heated  air — exist.     Its  daily  employment  will  relieve 


104  VOCAL   AND   RESPIRATORY  APPARATUS. 

the  dry  irritated  condition  of  the  mucous  membrane, 
and  act  as  a  preventive  of  nasal  catarrhs  by  removing 
the  excess  of  dust. 

Picking  of  the  nose  is  a  very  unhygienic  habit. 
Most  of  the  nose-bleeding  in  children  is  due  to  the 
finger-nail  injuries  of  the  mucous  membrane  of  the 
septum,  causing  small  crusting  ulcers.  Removal  of 
these  crusts  is  likely  to  be  followed  by  nose-bleed. 
The  hair-follicles  at  the  nasal  entrance  are  also  liable 
to  be  infected  by  the  finger,  and  boils  result.  All 
conditions  which  favor  drying  of  nasal  secretions 
foster  the  habit  of  nose-picking  in  children.  A  few 
drops  of  vaselin  brushed  into  the  nostrils  of  chil- 
dren will  do  much  to  prevent  crusting,  as  all  oils  dis- 
solve crusts. 

Abscess  and  suppuration  of  tlie  antrum  of 
Highmore,  the  air-cavity  in  the  upper  jaw,  is  often 
due  to  decay  of  teeth  whose  roots  project  into  the 
antrum.  Care  of  the  teeth  is  necessary  to  prevent 
this  form  of  disease. 

THE  NASOPHARYNX. 

The  space  back  of  the  nose  is  called  the  naso- 
pharynx. Its  roof  is  formed  by  the  base  of  the  skull, 
its  back  wall  by  the  vertebrae  of  the  neck,  its  front 
by  the  posterior  ends  of  the  nostrils,  its  lateral  walls 
by  the  Eustachian  tubes,  which  project  into  the  naso- 
pharynx and  supply  the  ear  with  air.  A  deep  re- 
cess, called  the  fossa  of  Rosenmliller,  lies  back  of  the 
Eustachian  tube  and  completes  the  lateral  wall.  The 
floor  is  formed  by  the  soft  palate,  behind  which  there 
is  an  open  space  leading  into  the  pharynx.  This  is 
closed  when  the  soft  palate  is  made  tense  and  ele- 


TJIJ'.    NASOPJIARYNX. 


105 


vated.  In  children  the  greater  part  of  tlie  roof  of 
the  nasopharynx  is  covered  by  what  is  called  tlie 
third,  or  I^nschka's  tonsil.  The  evil  effects  of  en- 
largement of  this  tissne  by  adenoid  growth  have  al- 
ready been  referred  to  as  far  as  stoppage  of  respira- 
tion is  concerned,  bnt  another  important  danger  of 
this  condition  is  pressure  on  the  Eustachian  tubes 
interfering  with  the  ventilation  of  the  middle  ear — a 
common  cause  of  deafness  in  children  (see  page  157). 

Ji/ptrict  •WM/Wfl/ 


Fig.  23. — Pharyngeal  tube-mouth,  as  seen  by  posterior  rhinoscopy. 

Habitual  stopping  up  of  the  nose  in  children  is 
therefore  always  to  be  taken  seriously,  as  chronic  deaf- 
ness may  result  from  neglect  of  this  condition.  The 
best  treatment  of  enlargement  of  the  third  tonsil 
is  its  removal  by  operation.  As  it  is  a  condition  oc- 
curring in  the  hardiest  and  healthiest  children,  there 
seems  to  be  no  means  to  avoid  its  occurrence.  In 
adults  enlargement  of  the  third  tonsil  usually  disap- 
pears by  atro])h5^,  but  not  until  the  nasopharynx 
becomes  the  seat  of  frequent  catarrhal  attacks. 

The  catarrhal  states  of  the  nasopharynx  are  due 


I06  VOCAL   AND   RESPIRATORY  APPARATUS. 

to  the  same  causes  as  those  of  the  nose,  and  their  pre- 
vention requires  the  measures  already  described. 
Catarrhal  conditions  of  the  nasopharynx  should  not 
be  neglected,  as  they  endanger  the  hearing  by  the 
possible  involvement  of  the  Hustachain  tubes  and 
middle  ear.  Deafness  is  also  favored  by  nasal  ob- 
struction, as  in  such  condition  the  act  of  swallowing 
causes  a  partial  vacuum  to  form  in  the  nasopharynx 
which  sucks  the  air  from  the  middle  ear,  drawing  in 
its  little  chain  of  bones  and  stopping  their  vibratory 
motions. 

THE  OROPHARYNX. 

Anatomy  and  Physiology. — Below  the  naso- 
pharynx and  continuous  with  it  is  the  oropharynx,  or 
part  of  the  pharynx  connecting  with  the  mouth.  It 
is  directly  visible  through  the  mouth,  while  the  naso- 
pharynx is  only  visible  by  means  of  the  laryngeal 
mirror  and  reflected  light.  The  oropharynx  is  con- 
tinuous with  the  cavity  of  the  mouth,  but  is  separated 
from  it  by  the  isthmus  of  the  fauces,  a  narrowing 
caused  by  muscles  which  are  continuous  with  the  soft 
palate,  and  form  what  are  called  the  anterior  and  the 
posterior  pillars  of  the  fauces.  Between  these  lie  the 
tonsils,  also  called  faucial  tonsils.  The  posterior 
wall  of  the  oropharynx  is  continuous  with  that  of  the 
nasopharynx,  and  lies  in  front  of  the  vertebrae  of  the 
neck.  Its  anterior  wall  is  formed  by  the  back  of  the 
tongue.  The  oropharynx  is  used  for  both  respiration 
and  swallowing.  It  is  a  part  of  the  throat  that  is 
very  resistant  to  disease,  while  the  tonsils  in  front  of 
it  are,  perhaps,  more  liable  to  infections  than  any 
other  part  of  the  body. 


THE    TONSILS.  IO7 

The  tonsils  are  often  enlarged  as  the  resnlt  of  chronic 
hypertrophy,  and  are  then  an  obstruction  to  respira- 
tion and  cause  injury  to  the  voice.  Many  tonsils  that 
do  not  enlarge  are  subject  to  constantly  recurring  in- 
flammation, due  to  repeated  microbic  invasion.  An 
enlarged  tonsil  is  especially  likely  to  be  the  seat  of 
diphtheritic  infection,  making  it  a  constant  menace 
to  its  possessor.  The  evil  effects  of  enlarged  tonsils 
on  breathing  and  hearing  are  not  nearly  so  marked  as 
those  of  the  enlarged  pharyngeal  tonsil.  Neverthe- 
less, the  tonsils  are  often  removed,  as  they  are  visible 
and  easy  of  access,  while  the  worse  offender,  the  third 
tonsil,  is  left  behind.  In  many  persons  the  tonsils 
are  frequently  infected  with  pus  microbes,  causing 
repeated  abscesses  around  them.  Children  suffer- 
ing from  enlarged  tonsils  often  show  a  marked  gain 
in  weight  and  health  after  their  removal,  and  in 
adults  continually  recurring  infection  necessitates 
treatment  and  often  removal  of  the  tonsils  before 
proper  hygiene  of  the  throat  can  be  practised. 

The  Tongue, — The  back  of  the  tongue  is  often 
covered  with  masses  of  thickened,  decomposing  epi- 
thelium, which  may  extend  forward  to  the  tip  and 
cause  visible  "coating  of  the  tongue."  It  is  this 
epithelium  at  the  back  of  the  tongue  which  is  the 
cause  of  most  cases  of  bad  breath  where  there  is  no 
actual  disease  to  account  for  it.  Scraping  off  these 
masses  from  the  back  of  the  tongue,  as  far  back  as 
one  can  reach  with  the  ring  of  one  handle  of  a  pair 
of  scissors,  removes  this  bad  smelling  material. 
Most  persons  do  not  know  that  the  base  of  the  tongue 
is  often  the  site  from  which  bad  breath  arises,  and 
attribute  it  to  catarrh.     The  cause  of  coatiuQ-  of  the 


io8 


VOCAL   AND   RESPIRATORY  APPARATUS. 


tongue,  whether  of  gastric  origin  or  due  to  some 
throat  disorder,  is,  of  course,  a  subject  for  medical 
treatment. 

The  laryngopharynx  is  the  lowest  division  of 
the  pharynx,  and  is  situated  behind  the  larynx. 
Below  this  it  becomes  the  esophagus.  It  is  not  much 
subject  to  disease  of  a  preventible  order,  but  is  a 
place  of  frequent  lodgement  of  foreign  bodies,  fish- 
bones, and  the  like. 

THE   LARYNX. 

The  larynx  is  placed  in  front  of  the  lowest  part  of 
the  pharynx,  and  is  composed  of  a  number  of  carti- 
lages. The  largest  of  these, 
the  thyroid,  forms  the  greater 
part  of  the  front  of  the  larynx, 
and  has  somewhat  the  shape 
of  a  shield.  Below  and  behind 
it  is  the  cricoid  cartilage,  with 
which  the  thyroid  articulates, 
being  freely  movable  upon  it. 
The  cricoid  cartilage  has  the 
shape  of  a  signet  ring,  with  the 
broad  part  of  the  ring  behind. 
On  the  top  of  this  broad  por- 
tion rest  two  small,  very  mov- 
able cartilages,  of  pyramidal 
shape,  the  arytenoid  carti- 
lages. To  the  front  end  of 
these  are  attached  the  strong, 
band-like  structures  of  white, 
fibrous  material,  called  the 
vocal  cords,  the  instruments  of  sound  for  the  voice. 


Fig.  24. — Lateral  view  of  lar- 
ynx in  its  relation  to  the  hyoid 
bone  and  trachea. 


TIIF.     VOCAI.    CORDS. 


109 


The  vocal  cords  are  strctclicd  between  the  aryte- 
noid cartilages  behind  and  the  thyroid  cartilage  in 
front.  They  are  attached  in  front  and  laterally  to  the 
thyroid  cartilage,  posteriorly  to  the  arytenoid  carti- 
lages. 

The  larynx  has  many  muscles  of  small  size.     Some 


Image  0/ ^ 
epiglottis 


linage  of  vocal _ 
cords 


Fig.  25. — Schematic  view  of  the  tongue-base,  epiglottis,  arytenoids  and 
ary-epiglottic  folds,  ventricular  bands,  and  vocal  cords,  with  the  larj'ngo- 
scopic  reflection. 


of  these  move  the  cricoid  backward  from  the  thyroid 
cartilage  in  such  a  way  that  the  vocal  cords  are  made 
tense  ;  others  move  the  arytenoid  cartilages  so  that 
they  bring  the  vocal  cords  together,  and  others  move 
these  cartilages  apart,  so  that  the  space  between  the 


no 


VOCAL   AND  RESPIRATORY  APPARATUS. 


vocal  cords,  or  glottis,  as  it  is  called,  opens  for  breath- 
ing. If  these  last  muscles  are  paralyzed  the  vocal 
cords  come  together  and  cannot  open,  so  that  there  is 
danger  of  suffocation.  There  is  a  muscle  seated  in 
the  vocal  cord  that  regulates  its  tension  and  makes 
the  wonderfully  fine  adjustments  of  the  voice  possible. 
It  is  called  the  musculus  vocalis,  or  th3^ro-aryte- 
noideus.  For  a  more  detailed  description  of  the 
laryngeal  muscles  the  reader  is  referred  to  works  on 
anatomy. 

In  looking  into  a  larynx  with  the  laryngoscopic 
mirror  (Fig.  25)  the  most  conspicuous  structures  we 
see  are  the  vocal  cords,  two  white  glistening  bands  ex- 
tending forward  and  back.  They  stand  wide  apart  at 
their  posterior  ends  during  quiet  breathing,  leaving 
a  triangular  opening,  which  permits  a  view  down  the 
trachea,  or  windpipe.  When  a  sound  is  made  the 
vocal  cords  can  be  seen  to  come  together  and  touch 


Fig.  26, — The  laryngoscopic  image  in  deep  inspiration  and  in  phonation. 


each  other  with  their  inner  borders.  In  front  of  and 
above  the  cords  we  see  the  epiglottis,  a  leaf-shaped 
structure  which  curls  above  the  larynx,  and  is  designed 
to  cover  it  during  swallowing  of  food  or  liquids.  At 
the  posterior   ends   of  the  vocal  "cords   we  see  two 


FUNCTIONS    OF  THE   LARYNX.  Ill 

rouiidisli  bodies,  which  move  out  and   in  with    the 
cords.     These  are  the  arytenoid  cartilages. 

Functions  of  the  Larynx. — During  inspiration  tlie 
vocal  cords  may  be  seen  to  move  automatically  apart, 
coming  slightly  together  again  during  expiration. 
The  larynx  has,  therefore,  as  its  first  function  that  of 
respiratory  opening  for  the  passage  of  air  to  the 
lungs,  for  which  purpose  it  is  needful  that  the  vocal 
cords  should   be   held  apart  by  the  proper  muscles. 

Another  function  of  the  larynx  is  to  guard  the 
lower  air-passages  from  the  entrance  of  foreign  bodies. 
Bven  a  small  object  entering  the  larynx  causes  at 
once  a  spasm  of  the  vocal  cords,  that  brings  them 
together  so  tightly  that  nothing  can  pass  them. 
This  spasm  may  be  lasting  enough  to  cause  symptoms 
of  suffocation  with  blueness  of  the  face  ;  even  death 
may  occur  before  the  spasm  relaxes. 

The  most  important  function  of  the  larynx  is  the 
production  of  voice-sounds.  For  this  purpose  three 
things  are  necessary :  The  bellows,  supplied  by  the 
lungs  ;  the  vibrating  membranes,  the  vocal  cords  ; 
and  the  pipe,  or  trumpet,  beyond  them,  supplied  by 
the  cavities  of  the  nose,  pharynx,  and  mouth.  For 
the  production  of  sound  the  vocal  cords  must  be 
brought  together  and  made  tense  by  the  laryngeal 
muscles.  The  higher  the  tone  of  the  sound  to  be 
produced  the  more  tense  are  the  vocal  cords,  and  the 
higher  the  larj'ux  is  raised  in  the  pharynx,  thus 
diminishing  the  length  of  the  pipe,  or  tube,  attached 
to  the  larynx,  which  has  been  likened  to  the  part  of 
a  trumpet  beyond  the  vibrating  reed.  For  low  tones 
the  larynx  is  lowered  or  descends  ;  thus  the  trumpet 
is   lengthened.     This    raising  and   loweriusf   of  the 


112         VOCAL   AND  RESPIRATORY  APPARATUS. 

larynx  facilitates  the  production  of  liigli  or  low 
tones,  but  is  not  absolutely  necessary,  for  by  muscu- 
lar effort  the  changes  of  pitch  can  be  produced  with- 
out change  of  the  position  of  the  larynx.  This  mus- 
cular effort,  however,  is  a  severe  strain  for  the  voice, 
and  it  will  be  referred  to  under  the  hygiene  of  the 
singing  voice.  The  up  and  down  motions  of  the  lar- 
ynx can  be  tested  by  anyone  who  feels  of  the  organ 
during  the  production  of  low  or  high  notes. 

The  Production  of  Voice-Sounds. — While  the 
pitch  of  the  voice  is  mainly,  therefore,  furnished  by 
the  vocal  cords,  its  timbre,  or  quality,  depends  chiefly 
on  the  pharyngeal,  nasal,  and  mouth-passages.  It  is 
possible  to  permit  the  air  to  pass  through  the  mouth 
only,  when  a  sound  is  made,  the  soft  palate  shutting 
off  the  nose  from  the  mouth ;  or  the  air  may  be  al- 
lowed to  go  only  through  the  nose,  or  through  both 
nose  and  mouth  together.  Endless  slight  modifica- 
tions of  these  conditions  are  possible,  so  that  the  vol- 
untary changes  in  the  quality  of  the  voice  by  altera- 
tion of  the  position  of  the  soft  palate,  lips,  tongue,  or 
pharyngeal  muscles  are  innumerable. 

So  much  do  the  shape,  size,  and  position  of  the 
air-passages  attached  above  to  the  larynx  affect  the 
quality  of  the  sound  produced  that  there  are  no  two 
voices  exactly  alike,  and  individuals  can  be  recog- 
nized by  their  voices  alone. 

For  convenience  we  will  call  the  oral,  pharyngeal, 
and  nasal  passages  above  the  larynx  the  attached 
tube.  If  the  larynx  is  detached  from  this,  as  it  is  at 
times  in  cases  of  cut-throat,  it  makes  a  feeble  sound 
only.  This  shows  that  the  attached  tube  not  only 
gives   quality  to  the  voice-sounds,    but  intensity  as 


CARE    OF   THE    VOICE.  113 

well,  acting  in  this  way  similarly  to  a  speaking- 
trnnipet.  The  respiratory  function  of  the  larynx  is 
interfered  with  only  by  actual  disease  severe  enough 
to  so  narrow  the  air-passages  as  to  cause  shortness  of 
breath. 

The  Care  of  the  Voice. — A  pleasing  speech  and 
voice  are  almost  equal  to  personal  appearance  in  im- 
portance to  the  individual  in  his  relations  to 
others.  A  great  number  of  complex  movements  are 
needed  to  produce  proper  speech,  and  these  are  ac- 
quired slowly  and  with  difficulty.  In  fact,  a  center 
for  these  delicate  coordinated  movements  has  to  be 
developed  in  the  brain  as  the  child  grows.  Speech  is 
largely  the  result  of  imitation,  and  if  the  voices  a 
child  hears  are  harsh  or  coarse  so  will  its  own  be- 
come. The  best  way  therefore  to  teach  a  child  dis- 
tinct and  refined  speech  is  to  let  it  hear  such  only. 
However,  this  is  not  always  all  that  is  sufficient. 
Enlarged  tonsils  and,  still  more,  adenoid  vegetations 
block  the  way  of  the  sound-waves  to  the  nasal  cav- 
ities after  they  leave  the  larynx.  This  deprives  the 
voice  of  both  intensity  and  resonance,  and  compels 
the  child  to  adjust  its  laryngeal  muscles  and  those 
of  articulation  to  the  strain  thus  thrown  upon  them. 
This  interferes  with  the  acquirement  of  the  delicate 
coordination  of  the  muscles  needed  for  distinct  speech, 
and  such  children  usually  have  an  imperfect  utterance. 
The  number  of  people  that  are  allowed  to  grow  up 
handicapped  by  hast}^,  slurred,  harsh,  disagreeable 
speech  and  voice  is  great.  Parents  do  not  seem  to 
appreciate  the  advantage  to  their  children  in  after- 
life that  a  refined,  melodious  voice  will  be. 

Proper  singing  is  one  of  the  best  modes  of  cultivat- 


114         VOCAL  AND  RESPIRATORY  APPARATUS. 

ing  a  pleasant  speaking  voice,  even  if  the  singer  has 
no  chance  of  anything  more  than  a  place  in  a  chorus. 
It  is  a  delight  to  hear  a  good  singer  speak,  and  often 
we  can  tell  that  a  person  is  a  singer  simply  from  the 
speech.  Improper  singing  is  not  only  a- distress  to 
others,  but  soon  ruins  at  least  the  singing  voice. 

Children  should  be  encouraged  to  sing.  It  paves 
the  way  to  singing  in  adult  life,  and  as  they  are  not 
self-conscious  and  not  afflicted  with  improper 
"  methods"  they  do  not  strain  their  laryngeal  muscles, 
especially  as  the  tunes  they  sing  are  within  easy 
reach  of  their  voices.  This  presupposes,  of  course, 
that  there  are  no  obstructions  to  the  passage  of  sound- 
vibrations  in  the  upper  air-passages,  such  as  enlarge- 
ment of  either  the  faucial  or  the  pharyngeal  tonsils. 
Of  course,  children  with  hoarseness  due  to  laryngeal 
ailments  cannot  sing.  Those  with  an  imperfect  ear 
for  music  may  be  improved  vastly  by  persistent  efforts 
to  sing  true.  When  a  child's  voice  is  changing, 
singing  should  be  prohibited  until  the  adult  type  of 
voice  has  been  fully  developed.  This  is  true  of  girls 
as  well  as  boys.  Singing  is  an  excellent  form  of  re- 
spiratory gymnastics,  and  tends  to  develop  a  full,  well- 
formed  chest.  In  this  way  it  acts  as  a  preventive  of 
lung-diseases. 

Loss  of  the  adult  singing  voice  means  loss  of  occu- 
pation to  professional  singers,  and  to  amateurs  the 
loss  of  a  valued  social  quality.  All  singers  know 
what  uncertain  possessions  their  voices  are.  Many 
voices  deteriorate  early,  or,  giving  good  promise  at 
first,  do  not  stand  the  training  and  lose  their  tone; 
and  this  is  not  without  reason. 

One  of  the  first  causes  of  voice-deterioration  is 


iMPRorjiR  JMF/rnoj)  jn  singing.  115 

imperfect  general  health.  Feeble  persons,  with  weak 
mnscles  and  imperfect  nntrition,  cannot  develop  a 
good  voice,  nor  can  those  maintain  it  whose  health 
has  failed.  Being  non-resistant  to  disease  because  of 
low  general  vitality,  the  part  put  upon  the  greatest 
strain,  the  larynx,  is  subject  to  repeated  catarrhs  and 
to  early  fatigue  in  singing.  This  strain  of  the  mus- 
cles of  the  larynx  soon  results  in  loss  of  the  singing 
voice. 

A  second  prolific  cause  of  loss  of  the  singing  voice 
is  persistence  in  singing  during  attacks  of  acute 
laryngitis,  a  persistence  often  rewarded  with  the 
chronic  form  of  the  disease.  There  is  thickening  of 
the  mucous  membrane,  interfering  with  the  action  of 
the  laryngeal  muscles,  hindering  approximation  of 
the  cords,  and  causing  the  muscles  to  be  used  too 
energetically  in  order  to  overcome  the  abnormal  re- 
sistance, so  that  their  delicately  fine  adjustment  be- 
comes quite  disordered.  In  such  cases  the  singer's 
notes  become  untrue  in  pitch.  During  attacks  of 
laryngitis  the  voice  should  have  as  nearly  perfect  rest 
as  possible.  Neither  should  a  singer  use  his  voice 
during  an  attack  of  cold  in  the  head,  as  the  abnormal 
obstruction  to  the  sound-waves  caused  by  the  swollen 
mucous  membrane  of  the  nose  disturbs  the  adjust- 
ment of  the  laryngeal  muscles. 

The  commonest  cause  of  voice-injury  is  improper 
method  in  singing.  A  singer  with  proper  control 
of  his  voice  adjusts  the  vocal  cords  and  the  at- 
tached tube  so  perfectly  by  exact  muscular  action 
that  not  only  is  no  power  wasted,  no  muscle  made 
tense  that  is  not  necessarily  so,  but  also  the  proper 
position  is  attained  at  once,  so  that  the  moment  the 


Il6  VOCAL   AND   RESPIRATORY  APPARATUS. 

bellows  (lungs)  force  air  through  the  larynx,  the 
exact  pitch  and  loudness  desired  are  attained  and 
held.  In  other  words,  the  voice-muscles  of  a  good 
singer  are  as  perfectly  under  his  control  as  are  the 
muscles  used  in  keeping  the  balance  of  an  expert  in 
bicycling.  As  with  other  muscles,  those  of  the 
larynx  subjected  to  excessive  action  tend  to  become 
strong  and  slow,  while  delicate  adjustments  are  lost. 
In  other  words,  they  become,  as  gymnasts  say,  mus- 
cle-bound. All  improper  modes  of  singing  include 
needless  strain  of  the  voice-muscles,  and  so  interfere 
with  their  exact  adjustment  and  cause  them  to  con- 
tract too  forcibly,  so  stiffening  their  action. 

One  of  the  worst  faults  is  a  rigid  position  of  the 
larynx,  its  up  and  down  motion  being  inhibited, 
producing  a  "throat  voice."  This  involves  tense 
contraction  of  many  muscles  that  should  be  relaxed, 
and  thus  compels  them  to  work  under  great  disad- 
vantage. One  can  hardly  believe  that  this  imperfect 
method  of  singing  with  suspension  of  the  normal 
up  and  down  motions  of  the  larynx  is  a  part  of  a 
"method"  taught  by  certain  vocal  instructors.  A 
disagreeable  tremolo  is  one  of  the  bad  effects  of 
singing  forte  under  these  conditions,  and  an  annoy- 
ing forced  or  pressed  sound  of  the  voice  also  re- 
sults. Another  of  the  evil  effects  of  this  strained 
way  of  singing  is  chronic  laryngitis  with  thickening 
and  excrescences  of  the  vocal  cords.  This  is  true 
of  any  other  improper  and  strained  mode  of  using 
the  voice,  though  the  resistance  of  the  larynx  to 
abuse  varies.  A  voice  which  is  used  out  of  its  nor- 
mal register,  especially  if  there  is  a  constant  strain- 
ing after  high  notes,   is  one  that  will  not  last  long. 


EXCESSIVE    USE    OF   THE    VOICE.  WJ 

Singing-teachers  commit  great  errors  in  yielding  to 
the  ambitions  of  pupils,  or  in  not  being  careful 
enough  in  determining  the  normal  voice  in  question, 
allowing  altos  to  attempt  to  be  sopranos,  and  baritones 
to  try  to  become  tenors,  etc. 

Excessive  use  of  the  voice  threatens  its  integrity, 
as  do  attempts  to  sing  difficult  music  before  the  voice 
has  been  sufficiently  trained.  The  action  of  the 
laryngeal  muscles  differs  from  that  of  many  others  in 
that  they  are  continually  and  with  great  exactness 
adjusting  the  position  and  tension  of  the  cords,  and 
holding  them  in  certain  positions.  This  renders 
them  especially  liable  to  injuries  after  prolonged 
fatiguing  contractions.  In  order  to  sing  well  and 
long,  careful  practice  is  needed  until  little  by  little 
the  muscles  learn  their  exact  adjustments.  By  im- 
proper use  of  the  voice  it  may  become  irretrievably 
damaged  and  even  actual  disease  of  the  larynx  may 
result.  No  one  should  sing  until  the  larynx  becomes 
fatigued,  but  an  attempt  should  be  made  by  easy 
stages  to  strengthen  the  voice-muscles  until  they 
acquire  more  endurance. 

Many  persons  in  speaking  or  singing  are  likely  to 
begin  the  vocal  sound  sforzando  with  sudden  em- 
phasis. As  this  implies  bringing  the  vocal  cords 
together  with  spasmodic  force,  such  practice  not 
only  produces  a  disagreeable  vocal  sound,  but  irri- 
tates the  free  borders  of  the  vocal  cords,  rendering 
them  liable  to  the  occurrence  of  small  prominences, 
called  singers'  nodes,  wdiicli  interfere  greatly  wdth 
the  clearness  of  the  voice.  This  spasmodic  action 
of  the  vocal  cords  is  called  the  "coup  de  glotte. " 

Some    strong,    robust    people   wntli    good    natural 


Il8  VOCAL   AND   RESPIRATORY  APPARATUS. 

voices  attempt  by  sheer  muscular  effort  to  overcome 
their  defective  vocal  education.  As  these  individuals 
have  not  learned  to  co-ordinate  their  laryngeal  mus- 
cles for  proper  united  action,  the  result  is  a  dis- 
agreeable tremolo.  Persons  with  weak  physique 
and  imperfect  development  should  strengthen  them- 
selves by  calisthenics  and  breathing-exercises  before 
beginning  to  sing.  Attention  to  the  general  nutri- 
tion of  the  body  is  also  needed.  Those  who  have  lost 
much  weight  or  have  not  fully  recovered  from  ex- 
hausting ailments  should  not  sing.  Here  it  is  that 
the  modern  method  of  forced  feeding,  having  the 
patient  limit  his  daily  amount  of  food  not  by  his  ap- 
petite, but  by  his  digestive  powers,  is  of  great  value. 
There  is  no  doubt  that  a  great  many  of  the  thin  in- 
dividuals of  the  community  suffer  from  self-imposed 
starvation,  as  their  appetites  from  nervous  causes 
fail  and  their  sense  of  hunger  is  lost,  while  their  di- 
gestive powers  are  unimpaired.  If  these  were  made 
use  of  to  their  limit,  they  w^ould  bring  a  return  of 
weight  and  strength.  Constricting  garments,  espe- 
cially corsets,  should  not  be  worn,  as  they  interfere 
with  the  chest-expansion,  the  sustaining  of  tones,  and 
the  regulation  of  the  air-current  supplied  by  the  res- 
piratory muscles. 

The  manner  of  using  the  vocal  organs  in  practis- 
ing singing  is,  of  course,  a  matter  best  left  to  sing- 
ing-teachers; but  as  these  are  not  all  competent,  an 
attempt  has  been  made  to  furnish  some  knowledge  as 
a  guide  to  those  who  desire  to  sing,  knowledge 
which  it  is  hoped  will  help  them  to  tell  whether  or 
not  they  are  in  good  hands  when  they  begin  to  take 
singing-lessons. 


THE   CHEST  AND   LUNGS. 


I  10 


THE  CHEST  AND  LUNGS. 

The  hygiene  of  the  respiratory  organs  within  the 
chest  inchides  a  consideration  of  the  thorax,  the  re- 
spiratory muscles,  and  the  hnigs. 

The  thorax,  or  chest-cavity,  is  formed  1)\  the  at- 
tachments of  the  ribs,  their  costal  cartilages,  and  the 
sternum,  to  the  spinal  column.  The  latter  is  the  fixed 
base  to  which  the  other  movable  parts  of  the  chest 

Circuvi/crcncc  of  apex  of  thorax. 


Manubrium 
sterni 

Costal  ca  rtilages 
Gladiolus 


Ensifonn  carti- 
lage of  xiphoid 
ajff>endix 


Seventh  rib'-\ 


Eleventh  rib 


Eleventh  rib 


Circumference  of  base. 
Fig.  27. — Thorax,  anterior  view. 


are  fastened.  The  part  of  the  spinal  column  to 
which  the  thorax  is  affixed  includes  the  twelve  dorsal 
vertebrae.  Twelve  ribs  on  each  side  of  the  body  are 
joined  to  it,  their  heads  forming  joints  with  the  bodies 
of  the  vertebrae,  while  their  necks  rest  on  the  strong 


126         VOCAL  AND   RESPIRATORY  APPARATUS. 

vertebral  transverse  processes,  moving  upon  them  and 
being  attached  to  them  by  another  joint  at  the  tip  of 
the  transverse  process.  The  ribs  end  in  front  in  the 
costal  cartilages,  which  are  really  elastic  prolonga- 
tions of  the  ribs.  The  costal  cartilages  of  the  first 
seven  ribs  join  the  breast-bone  directly;  those  of  the 
next  three  ribs  are  joined  to  the  costal  cartilages 
above;  while  those  of  the  last  two  ribs  are  unattached 
and  form  what  are  called  the  floating  ribs. 

The  breast-bone,  or  sternum,  closes  the  thorax  in 
front  and  moves  with  the  ribs,  forming  with  them  a 
movable  cage  enclosing  the  lungs. 

The  muscles  of  the  thorax  are  the  intercostals 
that  fill  the  space  between  the  ribs  and  complete  the 
chest- walls;  the  diaphragm,  which  closes  the  cavity 
of  the  chest  below,  separating  it  from  the  abdomen; 
and  the  auxiliary  respiratory  muscles,  or  muscles  of 
forced  breathing,  which,  however,  are  not  in  use 
during  quiet  breathing.  These  auxiliary  muscles  are 
the  scaleni,  arising  from  the  neck  vertebrae  and  in- 
serted into  the  upper  two  ribs;  the  sterno-cleido-mas- 
toid  muscles,  arising  from  the  skull  and  attached  to 
the  clavicle;  the  pectoralis  minor,  arising  from,  the 
scapula  and  inserted  into  the  third  and  fourth  ribs; 
and  the  serratus  posticus  superior  muscle,  arising  from 
the  spinal  column  and  attached  to  the  ribs. 

The  muscles  that  are  used  for  forced  expiration  are 
the  abdominal  muscles,  the  serratus  posticus  inferior, 
attached  to  the  spine  below  and  reaching  up  to  the 
ribs,  and  the  quadratus  lumborum  muscle,  which 
takes  its  fixed  point  from  the  pelvis  and  pulls  the  ribs 
downward. 

The  only  muscles  in  use  during  quiet  breathing  are 


TIIK    LUNGS. 


121 


the  intercostal  muscles,  the  diaphra<:^in,  and  the  leva- 
tores  costaruni  longus  et  brevus  muscles.  These  are 
all  muscles  of  inspiration.  Ordinary  expiration  re- 
quires no  muscular  effort  at  all,  as  the  weight  of  the 
thorax  and  the  elasticity  of  the  lungs  give  sufficient 
power  to  contract  the  thorax  and  expel  the  air,  the 


Right  co7ijmon, 

carotid  artery 

Subclavian 

arteries 

Innominate 

artery 

Arch  of  aorta' 
■  Right  lung 

Superior  vena 

cava 
Right  auricle 


Larynx 


Coronary 
artery 


Fig.  28. — Relation  of  lungs  to  other  thoracic  organs. 


ribs  dropping  back  into  the  expiratory  position  after 
being  lifted  by  the  inspiratory  muscles. 

The  lungs  are  composed  of  an  immense  number  of 
little  air-cells,  or  alveoli,  which  connect  with  the  outer 
air  by  means  of  the  bronchial  tubes.  These  begin 
as  tubes  of  microscopic  size,  which  unite  to  larger 
and  larger  ones  until  they  enter  the  windpipe,  or 
trachea,  by  means  of  a  large  bronchus,  or  air-tube,  for 


122  VOCAL   AND   RESPIRATORY  APPARATUS. 

each  lung.  The  larger  bronchial  tubes  are  stiffened 
with  rings  of  cartilage,  and  the  smaller  ones  down  to 
a  caliber  of  one  millimeter  with  cartilaginous  plates. 
The  smallest  bronchial  tubes  have  only  circular  mus- 
cle-fibers instead  of  cartilage.  The  air-cells,  or  alve- 
oli, are  coated  with  thin  pavement-epithelium  and 
have  the  greater  part  of  their  walls  composed  of  a 
dense  network  of  capillary  blood-vessels. 

The  function  of  the  air-cells  is  to  allow  the  red 
blood- eel  Is  to  absorb  oxygen  from  the  air  and 
give  off  the  carbon  dioxid  which  they  hold  partly 
in  chemical  combination  and  which  is  partly  also 
contained  in  the  fluid  blood.  The  lung  is  therefore  a 
gland  designed  to  take  in  and  excrete  the  gaseous 
constituents  of  the  blood.  The  red  blood-cells  do  not 
simply  absorb  the  oxygen  of  the  air,  but  take  it  into 
loose  chemical  combination  with  their  pigment  of 
hemoglobin.  This  in  turn  delivers  the  oxygen  to 
the  tissues  of  the  body.  The  blood  passing  through 
the  capillaries  of  the  air-cells  comes  from  the  pul- 
monary artery  and  right  ventricle  of  the  heart,  and  is 
venous  blood  while  in  this  vessel.  It  leaves  the  capil- 
laries lining  the  air-cells  to  enter  the  pulmonary 
veins  as  arterial  blood,  or  blood  which  has  taken  up 
oxygen.  The  lungs  have  a  further  blood-supply  for 
their  own  nutrition,  as  that  which  passes  through  the 
capillaries  of  the  pulmonary  artery  is  not  utilized  by 
the  lung  itself,  but  is  utilized  merely  for  the  pur- 
pose of  oxidation.  The  arteries  supplying  the  lungs 
with  nutrient  blood  are  called  the  bronchial  arteries, 
and  are  branches  of  the  aorta. 

The  walls  of  the  alveoli  of  the  bronchial  tubes  and 
of    the   interstitial    tissue   between    the    lobules,  or 


THE  MECHANISM  OE  RESPIRA'J'ION.  I  23 

clusters  of  air-cells,  at  the  end  of  a  bronchiole,  or 
minute  bronchus,  are  all  composed  largely  of  what 
are  called  elastic  fibers.  This  gives  to  the  lung  its 
rubber-like  power  of  elastic  retraction  after  expansion. 

The  lungs  are  not  attached  directly  to  the  chest- 
wall,  but  are  covered  by  a  smooth  glistening  mem- 
brane called  the  pleura.  A  similar  membrane  lines 
the  inside  of  the  chest-wall,  and  though  the  lungs  lie 
in  contact  with  this  wall  they  are  not  attached  to  it, 
as*  the  layer  of  the  pleura  covering  the  lung,  while  in 
touch  with  that  lining  the  chest-wall,  nevertheless 
glides  smoothly  upon  it  during  the  respiratory  motions. 
If  the  chest-wall  is  perforated,  the  lung  collapses  by 
reason  of  its  own  elastic  retractility,  air  meanwhile 
rushing  into  what  is  called  the  pleural  cavity  between 
the  two  layers  of  the  pleura.  In  health,  of  course,  there 
is  no  cavity,  as  these  layers  lie  against  each  other. 

The  lungs  are  kept  expanded  by  the  suction  of 
the  chest-wall,  and  in  health  never  entirely  collapse. 
The  inspiratory  muscles  lift  the  ribs  upward  and 
outward,  thus  increasing  the  capacity  of  the  chest 
in  its  circumference,  while  the  diaphragm  descends, 
increasing  the  capacity  vertically.  This  causes  an 
increase  of  the  negative  pressure  in  the  chest;  and  as 
in  health  air  cannot  enter  the  pleural  cavity,  the  lung 
must  follow  the  pulling  force  of  the  expanding  thorax 
and  fill  with  the  air  that  rushes  into  the  trachea. 

Ordinary  expiration  takes  place,  as  stated,  by  means 
of  the  retractile  power  of  the  lung  and  the  weight  of 
the  chest- walls,  no  muscular  effort  being  needed. 

It  is  obvious  that  when  expanding  the  lung  must 
not  only  suck  in  air  into  its  air-cells,  but  also  must 
draw  blood  into  its  capillary  vessels.     The  narrower 


124         VOCAL   AND   RESPIRATORY  APPARATUS. 

the  orifice  tlirougli  wliich  the  air  passes  the  more 
power  is  left  to  suck  in  blood,  so  that  nose-breathing 
is  an  aid  to  the  circulation  of  blood  in  the  lung,  while 
mouth-breathing  is  not.  The  thorax  loses  mobility 
and  expanding  power  in  later  life,  and  in  the  aged 
becomes  stiff  and  rigid.  The  motion  of  the  ribs  in 
their  sockets  becomes  limited,  while  the  elastic  costal 
cartilages,  which  are  twisted  or  undergo  torsion  during 
each  inspiration,  normally  become  too  stiff  to  yield  in 
this  way  to  the  inspiratory  pull.  Age  therefore  dis- 
qualifies for  violent  exertion,  as  this  rigidity  of  the 
thorax  gives  the  respiratory  muscles  more  work  to  do, 
and  breathlessness  comes  sooner  during  exertion  in 
age  than  in  youth.  By  continuing  gymnastics  and 
respiratory  exercises  through  life  the  greater  part  of 
the  mobility  of  the  thorax  can  be  maintained  till  a 
very  advanced  age.  This  is  an  argument  against  the 
theory  that  after  youth  is  passed,  gymnastics  are  of 
no  use. 

Deformities  of  tine  Thorax. — The  highest  effi- 
ciency of  the  lungs  as  organs  of  blood-oxygenation 
demands  a  well-formed  thorax;  yet  it  is  precisely  the 
thorax  that  of  all  parts  of  the  skeleton  is  most  often 
deformed,  a  fact  which  accounts  in  part  for  the  fre- 
quency of  lung-diseases. 

The  chest  is  simply  an  air-pump,  and  if  its  capacity 
is  diminished  by  being  bent  out  of  shape  it  can  obvi- 
ously suck  in  less  air  than  is  necessary.  This  is  also 
the  case  if  its  movements  are  restricted. 

In  the  extreme  chest-deformity  of  hunchbacks, 
in  which  in  parts  of  the  chest  there  is  no  movement 
at  all,  we  find  portions  of  the  lung  entirely  unex- 
panded,  forming  simply  a  fleshy  rriass.     This  exam- 


DEFONMI'J-JKS   OF    7I/J':    77/0 RAX.  I  25 

pie  of  great  defoniiity  shows  how  in  a  less  degree  the 
comiiiouer  deformities  of  the  chest  hinder  the  proper 
expansion  of  the  Inngs,  especially  within  the  parts 
most  deformed. 

The  most  freqnent  chest-deformity  is  scoliosis,  or 
lateral  curvature  of  the  spine,  with  twisting  of 
the  whole  spinal  colnmn  to  one  or  the  other  side, 
usually  the  right.  In  this  form  of  deformity  the 
shoulder  is  lower  on  one  side  than  on  the  other,  and 
the  relatives  and  teachers  of  the*  child  or  youth  so 
deformed  tell  him  to  lift  his  shoulder  and  stand 
"straight,"  imagining  that  the  deformity  is  in  the 
shoulders.  Scoliosis  contracts  the  side  of  the  thorax 
toward  which  the  spine  is  twisted.  There  is  ordi- 
narily another  spinal  deformity  associated  with  scoli- 
osis, called  kyphosis,  or  bending  of  the  spinal  column 
forward,  producing  a  thorax  rounded  behind  and 
flattened  in  front — the  typical,  flat-chested,  round- 
shouldered  person  which  is  so  often  the  product  of 
our  schools  (see  page  238).  Even  the  laity  know  from 
sad  experience  that  this  form  of  chest  predisposes  to 
consumption. 

The  effect  of  the  kypho-scoliotic  thorax  is  deficient 
expansion,  especially  of  the  apex  of  one  lung,  render- 
ing it  very  liable  to  tubercular  infection.  This  de- 
formity originates  chiefly  in  school,  on  account  of 
fatigue  of  the  muscles  which  maintain  the  spinal 
column  in  the  erect  position.  As  they  relax  from 
weariness  due  to  long  sitting  at  the  desk  the  column 
of  vertebras  bends  forward  and  rotates  toward  one  or 
the  other  side.  When  this  is  often  repeated  and  kept 
up  for  hours  at  a  time  from  compression  the  growing 
bones  become  permanently  misshapen,  and  deformity 


126    '    VOCAL   AND   RESPIRATORY  APPARATUS. 

results  which  lasts  through  life.     Kyphosis,  however, 
may  exist  without  scoliosis. 

The  prevention  of  spinal  deformities  requires,  in 
the  first  place,  seats  that  will  permit  a  child  to  rest  his 
spine  in  the  proper  position  of  erectness.  The  plane 
of  the  book's  surface  should  be  placed,  if  necessary,  by 
special  desk-attachments  almost  parallel  to  the  plane 
of  the  child's  face,  so  that  he  can  read  while  sitting 
erect  without  bending  over  his  desk.  The  possible 
factor  of  astigmatism  at  oblique  axis  in  the  early 
development  of  spinal  curvature  should  not  be  over- 
looked. 

Interruptions  of  study  by  calisthenic  exercises  de- 
signed to  give  vigor  to  those  muscles  that  counteract 
the  evil,  deforming  effects  of  prolonged  sitting  should 
occur  every  half-hour,  and  be  continued  for  five  min- 
utes at  a  time.  The  muscles  that  hold  the  spine 
erect  and  give  it  lateral  support  are  the  ones  to  be 
especially  strengthened  in  this  way.  Deformity  inva- 
riably results  whenever  muscular  support  is  removed 
from  any  part  of  the  skeletou,  as  the  ligaments  which 
unite  the  bones  stretch  under  strain,  for  they  are  sim- 
ply li miters  of  excessive  motion,  not  supports  of  the 
skeleton  like  the  muscles.  The  spinal  muscles  are 
quite  independent  of  those  that  move  the  shoulders. 
It  is  useless  to  tell  round-shouldered  persons  to  draw 
their  shoulders  back;  this  will  not  straighten  their 
backs.  The  shoulders  and  shoulder-girdle,  composed 
of  the  clavicles  and  scapulas,  are  only  secondarily  dis- 
placed by  the  spinal  deformity,  and  have  little  to  do 
with  an  erect  carriage.  The  spinal  muscles,  chiefly 
the  erector  spinae,  are  the  ones  to  be  exercised  while 
the  shoulders  are  being  held  loosely  and  in  a  state  of 
relaxation. 


''SIIOULDEK-BRACESr  12/ 

"Shoulder-braces"  are  absolutely  worthless  con- 
trivances, which  not  only  do  not  take  the  place  of  the 
spinal  muscles  in  holding  the  spine  erect,  but  make 
their  wearer  stiflf  and  ungainly  in  his  motions.  After 
growth  is  attained  much  can  be  done  at  least  to  partly 
overcome  those  spinal  deformities  the  correction  of 
which  has  been  neglected  during  growth.  Develop- 
ment of  the  spinal  muscles  is  also  indicated,  but  will 
not  accomplish  as  much  as  in  the  growing  period. 
In  overcoming  the  deformity  of  scoliosis  rotary  mo- 
tions of  the  spine  in  a  direction  opposite  to  its  natural 
faulty  twist  are  indicated. 

Symmetric  chests  without  actual  deformity  may  be 
narrow  and  of  limited  capacity,  with  deficient  expan- 
sion. The  tendency  to  this  form  of  chest  should  be 
counteracted  in  growing  years  by  special  attention  to 
respiratory  gymnastics  and  light  exercises,  such  as 
sparring,  running,  etc.  In  adults,  though  the  bony 
frame  of  the  chest  is  unchangeable  and  the  number 
of  air-cells  in  the  lungs  is  unalterable,  breathing-ex- 
ercises will  cause  the  limited  excursions  of  the  ribs  in 
their  joints  to  increase,  adding  thus  to  the  amount  of 
air  exhaled  and  inhaled,  and  making  the  chest  larger 
in  full  inspiration,  when  air-cells  heretofore  only  half 
expanded  become  fully  so.  The  chest  becomes  more 
roomy  because  of  the  greater  motility  of  its  parts,  not 
because  there  is  any  increase  in  their  size. 

The  fact  is  so  universally  appreciated  that  the  flat 
and  narrow  chest  with  wide  intercostal  spaces  pre- 
disposes to  consumption  of  the  lungs  that  it  is  called 
the  "  phthisical  thorax."  Pulmonary  tuberculosis  is 
found  much  less  often  in  persons  with  well-formed 
chests,  as  all  parts  of  the  lungs  are  equally  expanded 


128         VOCAL   AND  RESPIRATORY  APPARATUS. 

and  kept  healthy  by  use;  while  in  the  flat,  narrow 
chest  the  upper  parts  of  the  lungs,  or  apices,  get  little 
expansion,  and  experience  shows  that  these  portions 
are  especially  liable  to  tubercular  infection. 

The  purity  of  the  air  inhaled  is  next  to  a  well- 
formed  chest  in  importance  to  the  health  of  the  lungs. 
Nature  tries  to  make  the  air  dust- free  before  it  reaches 
the  finer  bronchial  tubes  and  alveoli,  but  in  spite  of 
the  many  safeguards  some  dust  penetrates  the  air- 
cells.  In  addition  to  the  upper  air-passages,  which 
arrest  most  of  the  dust,  the  bronchial  tubes, 
branching  angularly,  catch  nearly  all  that  remains 
before  it  enters  the  finer  bronchioles  and  air- 
cells.  The  dust  so  caught  is  moved  into  the  outer 
world  again  by  the  ciliated  epithelium  of  the  bronchi. 
Excessive  amounts  of  dust  irritate  the  larynx  and 
trachea,  and  cause  coughing-fits  which  expel  the 
noxious  particles.  Only  when  the  secretions  are 
excessive  is  coughing  needful  to  keep  the  lungs 
clear  ;  otherwise  a  balance  is  maintained  between 
the  supply  of  mucus  to  the  bronchi  and  the  amount 
needed.  The  dust  which  reaches  the  air-cells  is  taken 
up  by  the  leukocytes,  or  white  blood-cells,  as  they  are 
called,  and  carried  by  the  lymphatic  channels  to  the 
bronchial  lymph-glands,  where  the  dust  is  deposited. 
Microbes  entering  the  air-cells  are  carried  off  in  the 
same  way,  and  are  liable  to  excite  inflammation  and 
abscess  of  the  bronchial  glands.  This  occurs  so 
rarely,  though,  and  these  glands  are  so  very  tolerant 
of  large  amounts  of  dust,  that  they  may  be  regarded  as 
a  very  perfect  safeguard  to  the  lungs. 

Coal-dust  and  vegetable-dust  are  the  least  harmful 
to  the  lungs.     The  dust  of  metals  and  minerals,  if 


PREVENTION   OE   I'UBERCULOSIS.  I  29 

inhaled  long  enough,  is  one  of  the  chief  causes  of 
fibroid  phthisis.  The  methods  of  avoiding  dust- 
breathing  have  been  considered  sufficiently  in  that 
portion  of  this  chapter  referring  to  nasal  hygiene. 

Virulent  microbes  are  being  constantly  inhaled; 
but  only  under  conditions  of  impaired  resistance  due 
to  lowered  vitality  or  local  disease  in  the  lung  are 
they  liable  to  attack  the  individual.  The  diplococcus 
of  pneumonia,  for  instance,  which  is  present  in  the 
mouths  of  many  people  and  is  often  inhaled,  is  likely 
to  cause  pneumonia  if  the  person  who  has  inhaled  it 
has  had  a  severe  chilling. 

The  influenza  bacillus  is  a  germ  that  seems  cap- 
able of  causing  disease  in  almost  all  persons;  but  the 
infection  varies  greatly  in  severity,  the  aged  especially 
being  liable  to  the  grave  pneumonic  forms  of  influ- 
enza. 

The  bacillus  of  tuberculosis,  which  we  doubtless 
often  inhale  into  our  lungs,  in  those  of  lowered 
vitality  may  cause  pulmonary  tuberculosis,  called 
also  consumption  of  the  lungs  or  phthisis.  Again, 
there  may  be  a  special  predisposition  to  tubercular 
disease  in  some  individnals  which  makes  them  par- 
ticularly liable  to  be  attacked  by  the  microbe  even 
when  in  good  health.  This  predisposition  to  infec- 
tion by  the  bacillus  of  tuberculosis  may  be  noticed 
in  certain  varieties  of  animals,  the  ruminants,  as  a 
rule,  being  more  liable  to  tuberculosis.  A  damp  soil 
favors  the  development  of  tuberculosis. 

Prevention  of  Tuberculosis. — It  is  impossible  to 
avoid  inhaling  the  germs  of  disease  into  the  lungs  at 
some  time,  but  the  danger  of  infection  may  be  dimin- 
ished by  care  on  the  part  of  those  already  infected. 


130         VOCAL  AND  RESPIRATORY  APPARATUS. 

It  is  known  that  the  sputum,  or  expectoration,  of 
tubercular  patients  should  always  be  deposited  in 
fluid  and  not  allowed  to  dry.  If  the  sputum  dries  on 
the  floor  or  in  handkerchiefs,  it  is  likely  to  be  pulver- 
ized and  float  about  as  dust.  Thus  inhaled,  it  is  a 
means  of  spreading  tuberculosis.  The  sputum,  there- 
fore, should  be  caught  in  a  vessel  containing  fluid 
which  dissolves  the  tough  mucus,  the  best  being  a 
solution  of  lye.  A  stronger  disinfectant,  such  as  5 
per  cent,  aqueous  solution  of  carbolic  acid,  may  also 
be  used.  In  spite  of  care,  sputum  may  lodge  on  the 
edge  of  the  vessel,  so  that  this  should  be  protected 
from  flies,  as  they  may  carry  the  bacilli  about  and  in- 
fect food  or  light  on  wounds.  Patients  who  go  out 
of  doors  should  carry  cloths  to  cough  into,  or  a  paper- 
bag  which  can  be  burnt  with  the  cloths.  Of  course, 
most  patients  will  deposit  their  sputum  on  the  street, 
not  heeding  the  danger  in  which  they  place  the  pub- 
lic. Fortunately,  sunlight  and  the  open  air  soon  ren- 
der harmless  bacilli  deposited  out  of  doors.  Patients 
in  the  last  stages  of  the  disease,  too  weak  to  use  a 
sputum-cup,  should  have  a  large  pan  into  which  they 
can  drop  the  cloths  they  use  to  catch  their  sputum. 
These  cloths  are,  of  course,  to  be  burned.  It  is  es- 
pecially by  these  patients  who  are  near  death  that  the 
bacilli  are  spread,  as  precautions  are  little  observed 
by  either  patient  or  attendants  at  this  time. 

The  patients  should  be  taught  to  take  these  pre- 
cautions for  their  own  sake,  as  they  are  likely  to 
infect  healthy  parts  of  their  lungs  or  the  larynx  by 
inhaling  bacilli  derived  from  their  sputum.  A  room 
in  which  a  tubercular  patiefit  has  lived  should  be  re- 
peatedly and  thoroughly  disinfected   with  formalin, 


MAINTENANCE    OF  BODILY  HEALTH.  131 

wliicli  is  best  made  in  large  generators,  which  con- 
vert a  half  gallon  of  wood  alcohol  into  formalin  vapor 
in  a  short  time,  so  insuring  concentration.  At  the 
same  time  the  air  of  the  room  should  be  made  very 
moist  by  hanging  up  a  number  of  wet  sheets. 

Lately  it  has  been  claimed  that  in  coughing  and 
even  in  speaking  tubercular  patients  eject  into  the 
air  minute  particles  of  saliva  containing  bacilli. 
During  coughing  this  probably  occurs  to  a  slight  de- 
gree at  times;  but,  on  the  whole,  this  source  of  tuber- 
cular infection  is  very  unusual  and  does  not  justify 
compelling  consumptives  to  wear  cloth  masks  to  catch 
bacilli,  as  has  been  suggested.  During  coughing, 
however,  a  cloth  should  always  be  held  in  front  of 
the  mouth. 

The  sputum  of  patients  with  influenza,  pneumonia, 
or  bronchitis  should  be  disposed  of  in  the  same  man- 
ner as  that  of  tubercular  patients,  as  the  discharges 
from  the  lungs  in  these  diseases  also  contain  patho- 
genic germs. 

The  freedom  of  the  lungs  from  disease  more  than 
most  organs  depends  on  the  maintenance  of  a  high 
standard  of  bodily  health.  The  lungs  especially 
become  vulnerable  to  the  causes  of  local  disease  on 
account  of  poor  nourishment  of  their  tissues  due  to 
low  vitality.  Children  of  the  poorer  class,  often  ill-fed 
and  living  in  badly  ventilated  rooms,  are  more  liable 
to  pulmonary  and  bronchial  affections  than  those  liv- 
ing under  better  circumstances. 

Natural  immunity  plays  a  great  role  in  preventing 
tubercular  disease  in  many  whose  ill-health  would 
otherwise  render  them  liable  to  consumption;  but 
those   who   have    even   a  strong  hereditary  predis- 


132         VOCAL   AND   RESPIRATORY  APPARATUS. 

position  to  the  disease  can  usually  avoid  it  by  keeping 
up  a  robust  state  of  health.  On  the  other  hand,'  many 
have  their  natural  immunity  destroyed  by  certain  de- 
pressing causes,  especially  by  alcoholism  and  dia- 
betes. Habitual  drinkers  bring  upon  themselves  a 
disposition  to  tuberculosis  even  while  their  appear- 
ance remains  robust  and  their  weight  normal.  Ex- 
cessive use  of  alcohol  seems  to  neutralize  natural  im- 
munity to  the  disease.  The  vital  depression  which 
comes  on  with  advancing  age,  however,  is  accom- 
panied by  a  tendency  to  the  formation  of  fibrous  tis- 
sue, which  toughens  the  lungs  and  renders  them  less 
liable  to  consumption.  When  the  disease  occurs  in 
elderly  people  it  is  likely  to  assume  a  slow  and  rela- 
tively benign  type. 

Physical  training  of  a  tubercularly  inclined  youth 
should  receive  as  much  care  as  his  mental  develop- 
ment. Every  observer  sees  children  well  developed 
mentally  who  are  in  greatest  need  of  physical  devel- 
opment for  their  feeble,  light-boned,  flat-chested 
bodies;  bodies  that  must  serve  them  through  life,  a 
perpetual  hindrance  to  success  and  effort,  and  which 
are  the  cause  of  premature  aging  and  invalidism.  It 
is  only  during  the  growing  years  from  twelve  to 
twenty-four  that  physical  training  is  of  avail,  and 
it  is  strange  that  parents  appreciate  so  little  this  pro- 
moter of  the  health  and  beauty  of  their  children. 
Though  we  meet  with  some  remarkable  minds  in 
feeble  bodies,  ordinarily  these  minds  are  of  the 
receptive  order,  which  take  in  facts  readily  but  do 
not  possess  the  power  to  elaborate  or  apply  them. 

The  functions  of  the  heart  and  lungs  are  inti- 
mately connected,  and  it  is  necessary  to  mention  their 


EXERCISES.  133 

relations  in  consicleriiio;  this  subject.  Proper  develop- 
ineiit  of  the  muscles  of  the  Iwdy  implies  not  only  a 
strongly  developed  set  of  respiratory  muscles,  but 
also  a  strong  and  enduring  heart.  The  function  of 
respiration  is  a  great  aid  to  the  heart  in  maintaining 
the  circulation,  each  inspiration  and  expiration  forc- 
ing blood  as  well  as  air  into  and  out  of  the  chest.  A 
well-developed  thorax,  with  wide  respiratory  excur- 
sions, is  therefore  a  great  aid  to  the  heart  in  its 
work. 

Exercises  requiring  increased  breathing  should  be 
performed  with  deep  inspiration  and  expiration 
through  the  nose.  The  expiration  should  be  watched 
especially,  as  the  tendency  is  to  keep  the  lungs 
full  of  air  without  emptying  them  properly,  so 
that  many  athletes  suffer  from  acute  emphysema,  or 
dilatation  of  the  lungs.  All  exercises  causing  slow 
powerful  contractions  of  many  muscles,  as  lifting 
great  weights,  wrestling,  part  of  the  work  done  on 
the  horizontal  or  parallel  bars,  tend  to  develop 
powerful,  large,  but  slowly-acting  muscles,  and  throw 
a  strain  on  the  heart,  because  respiration  during  these 
acts  is  either  suspended  or  limited  while  the  thorax 
is  held  rigid.  The  chief  cause  of  acute  heart-strain 
or  dilatation  of  the  heart  is  sudden,  severe  muscular 
effort.  These  exercises  are  to  be  avoided  or  at- 
tempted in  moderation,  and  only  by  the  robust. 
They  are  certainly  of  little  use  to  those  who  wish  to 
develop  the  thorax,  as  the  respiratory  excursions  are 
too  limited  during  them. 

Another  class  of  exercises  tending  to  one-sided  mus- 
cular development  and  physical  strain  are  those  re- 
quiring  prolonged    muscular   efforts,    such    as   long- 


134         VOCAL  AND   RESPIRATORY  APPARATUS. 

distance  cycling,  rowing,  or  running.  In  moderation 
these  are  all  of  benefit,  but  tbe  tendency  to  overdo 
them  is  great.  Of  the  three,  running  is  by  far  the 
best,  as  the  thorax  is  not  held  rigidly  as  a  base  for  the 
attached  muscles,  but  is  free  and  unrestrained  in  its 
motions.  Running,  when  properly  performed,  is  one 
of  the  best  of  all  exerci.ses.  In  riding  the  bicycle  it 
is  highly  important  that  the  breathing  should  be 
deep,  full,  and  through  the  nose.  It  is  especially 
in  this  form  of  exercise  that  heart-strain  is  likely  to 
occur,  largely  because  the  thorax  is  held  rigidly  and 
the  breathing  is  shallow.  A  heart  which  has  once 
been  strained  and  dilated  by  imprudent  exertion  may 
apparently  regain  its  vigor,  but  it  is  usually  liable  to 
a  recurrence  of  the  affection  on  moderate  exertion, 
and  so  remains  a  weak  organ. 

The  best  exercises  for  developing  an  enduring  and 
robust  body  are  general  calisthenics,  the  so-called 
"  army  setting-up  drill."  Sparring,  vaulting,  hand- 
ball, and  all  work  of  this  light,  quick  class  are  to 
be  commended.  Swimming  also  is  a  fine  respiratory 
and  free-motion  exercise.  In  fact,  all  those  exercises 
furnishing  unrestrained  and  easy  motions  are  prefer- 
able to  feats  of  strength  or  endurance.  No  exercise 
should  be  continued  until  it  becomes  a  physical 
strain.  Although  the  two  may  be  easily  combined, 
sport  is  not  physical  culture,  for  the  latter  is  not  to 
be  pursued  for  amusement  only,  but  as  a  serious 
duty  to  one's  self  and  others.  '  No  one  should  neglect 
his  bodily  vigor. 

The  Influence  of  Climate  on  Consumption. — 
Those  with  very  strong  tubercular  tendencies  had 
better  seek  a  proper  climate  for  their  permanent  home 


CLIMATIC   TKl'lATMENI'  OF   TUBERCULOSIS.       1 35 

early  rather  than  postpone  tlie  change  of  residence 
until  the  appearance  of  the  disease.  Considering  the 
fact  that  whole  families  die  of  consumption,  one  after 
the  other,  this  preventive  measure  seems  fully  justi- 
fied. A  move  from  the  large  city  to  the  neighboring 
suburbs  is  often  of  benefit. 

The  chief  requisite  of  a  good  climate  is  the  op- 
portunity it  offers  to  live  out  of  doors  as  much  as  pos- 
sible. Certain  climates  are  often  looked  upon  as 
specific  cures  for  consumption ;  but  the  disease  origi- 
nates de  novo  in  any  climate,  and  its  course  is  in- 
fluenced favorably  by  proper  hygienic  measures  in  all 
climates.  We  must  not  overestimate  the  effect  of  the 
special  region  in  which  the  patient  is  placed,  though 
high  and  dry  localities  undoubtedly  have  a  favorable 
influence  on  the  course  of  the  disease. 

Adjuvants  to  Climatic  Treatment. — In  addition 
to  avoiding  as  much  as  possible  the  chance  of  infec- 
tion with  the  bacillus  of  tuberculosis,  persons  pre- 
disposed to  consumption  should  give  the  greatest 
care  to  their  bodily  nutrition  and  keep  their  weight 
up  to  the  normal  standard  by  judicious  feeding  with 
plain  fare — meats,  and  especially  bread  and  butter. 
They  should  avoid  gastric  pleasures  that  give  but 
little  nourishment  to  the  organism  and  only  contrib- 
ute to  disorder  digestion.  Reference  is  especially 
made  to  alcoholic  drinks  and  coffee,  to  excess  of 
sweets,  fruits,  pies,  and  the  like,  and  to  drinking 
of  large  amounts  of  ice  water,  causing  atony  and  di- 
latation of  the  stomach.  Chronic  nicotin-poisoning, 
fast  eating,  taking  fifteen  minutes  to  a  meal  instead 
of  forty,  violent  exercise  causing  heart-strain,  all  are 
factors   that    lower    vitalitv  and   which    should    be 


136         VOCAL   AND    RESPIRATORY  APPARATUS. 

avoided  by  those  predisposed  to  consumption.  A 
hygienic  life  and  a  dry  soil  are  far  greater  safeguards 
against  the  disease  than  the  false  sense  of  security  fur- 
nished by  a  certain  climate.  Keeping  up  the  body- 
weight,  maintaining  the  muscles  hard  and  firm,  and 
the  heart  strong  by  exercise,  and  good  food  are  safe- 
guards, and  all  but  those  greatly  predisposed  to  con- 
sumption may  feel  reasonably  sure  of  escaping  it  if 
they  do  not  neglect  them. 

Division  of  climates  may  be  conveniently  made 
by  levels. 

Tine  sea-level,  the  lowest,  furnishes  a  high  at- 
mospheric pressure  which  necessitates  only  moderate 
lung-expansion  during  exercise.  The  air  is  germ- 
free  and  dust-free  when  the  wind  is  on-shore.  The 
appetite,  nervous  system,  and  tissue-change  are  stim- 
ulated. However,  high  winds  prevail,  and  experience 
shows  that  this  is  not  a  good  climate  for  consump- 
tives. 

The  low  levels,  up  to  1200  feet,  lack  the  tonic 
properties  of  the  higher  levels  or  the  sea-level.  The 
temperature-changes  from  night  to  day  are  moderate. 
On  the  whole,  these  climates  are  not  suitable  for 
consumptives,  nor  for  those  who  are  relaxed  or  run 
down  and  need  stimulation. 

The  moderate  levels,  1200  to  3000  feet,  are  excel- 
lent for  delicate  people  who  need  stimulation  of  their 
nervous  system  and  appetite,  but  who  would  find  it 
hard  to  endure  the  great  changes  in  temperature  and 
the  difficulty  of  exertion  connected  with  life  in  the 
higher  altitudes,  which  require  a  strong  heart  and 
well-developed  respiratory  muscles.  Moderate  levels 
are  therefore  better  for  older  persons  with  more  or 


THE   IIWJIER   LEVELS.  I  37 

less  rigid  chest-walls.  The  air  in  these  regions  is  rela- 
tively pure. 

The  higher  levels,  above  3000  feet,  give  the 
effect  of  low  air-pressure;  the  air  is  rarefied  and  much 
colder  at  night  than  in  the  daytime.  Differences  in 
temperature  are  sudden  and  extreme.  The  air  is 
usually  dry  and  germ-free.  The  amount  of  blood 
passing  through  the  vessels  of  the  skin  and  lungs  is 
increased;  the  rarefied  air  makes  freer  respiratory 
movements  of  the  chest  needful.  More  water  and  heat 
are  lost  from  the  body,  causing  greater  tissue-change. 
Such  climates  are  suitable  for  the  more  robust, 
with  good  digestion,  in  whom  the  losses  due  to  rapid 
tissue-changes  can  be  readily  replaced.  On  the 
whole,  the  high  altitudes  are  the  best  for  a  person 
predisposed  to  consumption,  provided  he  is  not  deli- 
cate and  nervous,  or  that  age  has  not  made  his 
arteries  rigid  and  his  thorax  non-expansile,  and  that 
his  heart  is  sound. 

In  making  a  change  of  climate  one  should  always 
consider  whether  the  conditions  in  a  strange  place 
will  be  as  good  as  those  at  home.  Many  consump- 
tives would  have  fared  better  at  home  than  in  a  more 
suitable  climate  than  their  home  can  offer  if  con- 
nected with  this  new  climate  there  are  a  lack  of  nur- 
sing and  badly  cooked  food  at  some  boarding-house 
or  hotel.  For  those  who  seek  new  climates  to  avoid 
acquiring  consumption  it  is  of  first  importance  that 
in  their  new  surroundings  they  be  well  fed  and  have 
healthy,  airy  rooms  and  suitable  occupations.  It 
would  be  a  poor  move  for  a  man  living  a  healthy 
out-of-door  life  in  Illinois  to  assume  an  unhealthy 
indoor  occupation  in  Colorado. 


138         VOCAL   AND  RESPIRATORY  APPARATUS.- 

It  is  likely  that  the  greater  expansion  of  the  lungs 
with  air  and  the  better  blood-supply  due  to  deeper 
respiration  have  much  to  do  with  the  good  effects  of 
the  higher  altitudes  on  the  slower  and  milder  types 
of  consumption.  This  influence  is  liable  to  be  posi- 
tively unfavorable  in  rapidly  advancing  cases  with 
fever,  when  both  body  and  lungs  need  rest.  In  such 
cases  the  treatment  by  perfect  rest  in  the  open  air  in 
the  recumbent  position,  with  feeding  up  to  the  full 
limits  of  the  digestive  powers,  is  the  best  treatment, 
and  accomplishes  more  than  a  change  of  climate. 


THE   HYGIENE   OF   THE   EAR. 

By  B.  ALEX.  RANDALL,  M.D., 

OK  PHILADELPHIA, 

Professor  of  Diseases  of  the  Ear  in  the  University  of  Pennsylvania,  and  in 
the  Philadelphia  Polyclinic. 


The  hygiene  of  the  organ  of  hearing — as  of  each 
organ  of  the  body — depends  largely  upon  its  anatomy 
and  physiology.  The  essential  part  of  the  organ — 
the. nervous  apparatus  by  which  the  sound-waves  are 
received  and  conveyed  to  the  perceptive  centers — is 
so  deeply  placed  as  to  be  out  of  the  reach  of  most 
direct  influences  except  those  which  affect  the  whole 
body;  but  the  accessory  or  conducting  apparatus  is 
open  to  many  injuries  and  affections  which  may  be 
warded  off  by  hygienic  rules  such  as  may  be  considered 
strictly  aural.  These  rules  are  more  often  negative — 
the  forbidding  of  common  but  pernicious  interferences 
— and  may  be  summed  up  in  a  brief  "let  alone,"  as 
will  appear  in  the  detailed  consideration  of  the  sub- 
ject. Ivcaving  the  internal  or  percipient  portions 
of  the  ear  for  later  consideration,  we  are  primarily 
concerned  with  the  external  and  middle  portions,  and 
can  be  free  from  some  usual  misconceptions  with 
regard  to  these  only  by  studying  them  in  some  detail. 

THE   EXTERNAL   EAR. 

The  Auricle. — The  external  ear  is  a  moulding  in 
and  out  of  the  skin-surface,  and  is  governed  by  most 

139 


I40 


THE   EAR. 


of  the  rules  pertaining  to  the  general  cutaneous  sys- 
tem. It  comprises  the  projecting  auricle  and  the  de- 
pressed canal,  an  irregular  tube  which  penetrates  more 
than  an  inch  nearly  directly  in-ward.  Apart  from  its 
liability  to  injury,  frost-bite,  and  skin-affections,  the 
auricle  is  unimportant,  and  its  total  loss  does  not  ap- 
preciably affect  the  hearing  and  merely  causes  an  un- 
sightly deformity.  Its  imdeveloped  conditions  are 
often  accompanied  by  absence  or  incompetence  of 
more  valuable  deeper  structures,  to  which  any  defect 


Fossa  of  helix 
Afithelix 

Concha 
Antitra^us- 


—Helix 


Fossa  of  anthelix 


Tragus 


If Lobule 


Fig.  29. — External  ear. 

of  hearing  is  really  ascribable.  The  auricle  might  be 
passed  with  mere  reference  to  the  need  of  slow  thaw- 
ing after  frost-bite  but  for  the  need  of  a  few  words 
as  to  the  barbarism  of  wearing  earrings.  Fortunately, 
fashion  is  rather  setting  her  face  against  them ;  but 
this  is  little  felt  as  yet  in  the  lower  walks  of  life, 
where  the  tradition  that  piercing  the  ears  is  helpful 
to  sore  eyes  also  is  strong.  This  latter  superstition  is 
the  basis  for  the  not  uncommon  wearing  of  earrings 
among  sailors.  This  is  wholly  specious  unless,  as 
with  the  seton  of  the  older  surgeon,  a  strongly  coun- 


BLOOD-CVSr,    OR   " J/KA/A /OA/A:' 


141 


ter-irritatint^  sore  is  produced,  but  this  is  an  obso- 
lete measure  wholly  superseded  by  more  ratioual 
surgery.  Too  often  the  piercing  of  the  ears  has  been 
entrusted  to  Some  ignoraut  peddler  of  earrings,  and  a 
single  group  of  children  will  furnish  many  cases  of 
abscess,  more  or  less  severe,  resulting  from  his  use  of 


Fig.  30. — Abscess  of  the  lobule  after  piercing  for  earrings. 

an  infected  needle.  Severe  blood-poisoning  may  not 
be  usual,  but  some  deformity  is  likely  to  result.  Es- 
pecially in  the  colored  race,  a  fibrous  enlargement,  or 
"  keloid,"  may  arise  without  decided  septic  infection, 
may  grow  even  to  the  size  of  the  fist,  and  recur  in 
spite  of  skilful  removal  by  operation.  Such  results 
are  often  ascribed  to  the  earrings  being  too  heavy  or 
composed  of  base  metal ;  and  the  rings  rather  than  the 
primary  piercing  are  blamed  for  the  consequences 
that  follow. 

Of  decided  interest  also  is  the  blood-cyst,  or 
"  hematoma,"  of  the  auricle,  most  commonly  due  to 
injury  in  sparring,  foot-ball,  etc.,  but  occurring  also 


142 


THE   EAR. 


without  known  cause,  especially  in  the  insane.  Some 
have  even  held  that  the  formation  of  such  a  blood- 
cyst  may  be  prophetic  of  mental  trouble  not  yet  ap- 
parent. Often  painless  and  stubborn,  they  may  leave 
much  deformity,  since  the  cartilage  of  the  ear  depends 
for  its  nutrition  upon  the  fibrous  tissue  which  covers 
it,  and  this  is  lifted  away  from  its  place  by  the  effused 
fluid  being  poured  out  between  them:  softening  and 
shrinkage  are  therefore  likely  to  follow  the  tardy 
cure. 

The  hygiene  of  the  auditory  canal  or  meatus  is 
more  special.  Here  we  have  a  skin-lined  pocket 
more  than  an  inch  in  depth,  with  the  drum-head  at 
its  bottom  and  its  walls  supplied  at  the  outer  part 
with  hairs  and  glands.  The  narrowness  and  curvings 
of  the  canal  serve  to  keep  out  foreign  bodies— even 
dust  being  arrested  by  the  hairs,  which  act  like  a 
sieve,  and  by  the  wax-covered  walls. 

The  ear-wax,  or  cerumen,  is  a  thin  yellowish 
fluid  formed  by  glands  strictly  like  the  sweat-glands 
of  other  skin-surfaces.  It  thickens  into  a  yellow 
paste  as  it  dries  and  unites  with  the  little  flakes  of 
dead  skin,  and  it  tends  to  dry  and  fall  outward.  As 
the  glands  are  only  in  the  outer  two-thirds  of  the 
canal,  no  wax  forms  on  or  near  the  drum-head,  and 
when  found  in  this  vicinity  it  has  been  pressed  there 
by  meddlesome  interference.  All  skin-surfaces  are 
constantly  shedding  the  dry  dead  cells  of  the  outer 
layer;  but  this  should' be  more  imperceptible  on  the 
fine  skin  of  the  ear-canal  than  elsewhere.  Yet  the 
finest  scales  might  interfere  with  the  delicate  func- 
tion of  the  drum-head;  so  by  a  remarkable  provis- 
ion of  nature  its  cells  grow  so  much  faster  at  the 


THE  EAR-WAX,    OR    CERUMEN. 


143 


center  as  virtually  to  overflow  the  rest  of  the  surface, 
pushing  the  other  cells  before  them  over  the  edge  on 
to  the  adjacent  wall,  and  even  some  distance  along 
this  before  they  are  thrown  off.  Thus  the  drum-head 
keeps  itself  clean,  and  may  be  said  even  to  sweep  the 
neighboring  canal-walls  of  the  effete  material  loosened 
from  their  surfaces.  Then  the  wax  begins  to  gum 
into  scales  this  dandruff-like  material,  and  with  the 
help  of  the  stiff  little  hairs,  which  tend  to  get  caught 


Fig.  31. — Metal  cast  of  the  external  ear, 
showing  the  curves  of  the  canal. 


Fig.  32. — Cast  of  the  canal 

in  profile. 


under  it,  it  is  worked  toward  the  external  opening. 
The  movements  of  the  jaw  act  upon  the  outer  part  of 
the  canal,  as  is  easily  felt  by  a  finger  thrust  into  the 
ear,  and  furnish  power  enough  to  move  large  flakes 
of  wax  outward,  or  even  to  eject  them  upon  the 
shoulder.  Thus  a  healthy  ear  should  never  show 
much  more  than  enough  wax  to  render  sticky  the 
hairs  within  it,  and  the  owner  should  be  unconscious 
of  any  wax  coming  away. 

Wax  does  not  collect  in  a  healthy  ear.     No  appli- 


144  ^-^^  ^^^• 

ance  is  called  for  to  remove  it,  and  all  such  are  to  be 
condemned.  Yet  the  penetration  of  water  in  bath- 
ing or  other  unnatural  conditions  may  serve  to  agglu- 
tinate the  wax  into  masses  that  do  not  come  away 
naturally,  and  collections  may  take  place,  especially 
in  ears  not  healthy.  This  may  indicate  lessened 
rather  than  increased  wax-formation,  although  the 
accumulation  may  seem  astonishingly  great  when 
brought  to  light.  Often  it  is  in  those  who  take 
the  most  (misguided)  pains  to  keep  their  ears  clean 
with  scoops  or  mops  that  we  find  the  largest  and 
hardest  masses.  In  hospital  clinics,  coal-heavers 
and  others  employed  in  dusty  work  constitute  a 
large  number  of  the  ear-cases  showing  this  condition. 
Efforts  to  remove  collections  of  ear-wax  are 
likely  to  be  dangerous  and  futile,  and  should  be  en- 
trusted only  to. the  skilled  hand;  although  the  ease 
and  safety  with  which  the  expert  syringes  them  away 
may  make  his  fee  seem  too  easily  earned.  Only  those 
who  see  how  much  harm  is  frequently  done  by  the  in- 
experienced can  realize  that  the  value  of  such  service 
lies  as  much  in  what  is  avoided  as  in  the  good  work 
done.  Collecting  gradually  for  months  until  only  a 
small  slit  alongside  the  mass  admits  the  sound-waves 
to  the  ear,  the  entrance  of  a  little  moisture  or  even 
of  damp  air  may  swell  the  wax  enough  to  close  sud- 
denly all  passage-way  and  cause  sudden  deafness,  with 
perhaps  dizziness,  nausea,  cough,  or  other  curious 
and  at  times  most  distant  extraordinary  symptoms. 
These  may  pass  away  as  the  w^ax  dries  and  shrinks, 
only  to  return  under  similar  circumstances  of  com- 
pleteness of  closure.  Pain  is  not  usually  a  part  of 
the    trouble   unless    the   mass    has    been    displaced 


FOREIGN  BODIES   IN    THE   EAR.  1 45 

(Sind  pressed  down  upon  tlie  druiii-liead,  alUioiigli 
even  then  it  may  be  moulded  to  a  perfect  cast  of  the 
tympanic  membrane-surface  without  ^^cnuine  pain, 
which  must  therefore  usually  be  taken  as  an  indica- 
tion of  inflammatory  involvement  calling  all  the  more 
urgently  for  prompt  and  gentle  removal. 

Tradition  is  responsible  for  the  habit  of  dropping  oil 
or  other  fluids  into  the  ear  as  a  preliminary  "  to  soften 
the  wax;"  but  this  rather  tends  to  swell  the  mass 
and  increase  pressure  without  any  compensating 
advantage  in  facilitating  its  removal,  while  it  is 
utterly  reprehensible  as  a  supposed  substitute.  Care- 
ful, vigorous  syringing  with  hot  water  (105°-!  15°  F.) 
is  the  proper  procedure  for  removing  the  wax;  no 
better  solvent  than  hot  water  is  obtainable.  Yet 
syringing,  like  most  manipulations  of  the  ear,  may 
cause  dizziness,  or  even  fainting;  and  should  be  dis- 
continued and  the  patient  laid  flat  on  the  back  at 
the  first  symptoms  of  such  an  occurrence.  Ear- 
scoops  or  mops  are  permissible  only  in  the  hands 
of  a  skilled  aurist,  and  he  will  use  them  but  little. 
An  ear  that  has  been  syringed  and  freed  from  obstruc- 
tive material  should  generally  be  dried  as  thoroughly 
as  possible  and  protected  from  air  for  the  rest  of  the 
day  by  a  flake  of  cotton.  On  the  other  hand,  any 
habit  of  wearing  cotton  is  to  be  condemned  as  use- 
less, uncleanly,  and  prone  to  interfere  with  the  proper 
exit  of  wax.  Often  a  forgotten  plug  is  the  basis  of  a 
wax  collection  obstructing  the  canal. 

Foreign  Bodies  in  the  Ear. — The  months  or  years 

that  such  masses  may  remain  unnoticed,  or  at  least 

without  irritation,  in  the  ear  exemplifies  the  slight 

harm  that  may  arise  from  insects,  pebbles,  or  other 

10 


146  THE  EAR. 

objects  entering  the  canal.  A  living  insect  must  be 
smothered  with  oil,  vapor  of  chloroform  (which  can 
be  poured  like  a  fluid  from  a  drop  in  the  bowl  of  a 
spoon),  or  even  water,  lest  its  movements  cause  un- 
bearable distress;  but  any  dead,  inactive  object  is 
generally  devoid  of  irritating  effect.  Children  rarely 
introduce  beads  or  such  objects  deeper  than  the  soft 
portion  of  the  canal,  from  which  they  will  easily  fall 
out  if  the  head  be  inclined  to  the  side  and  the  canal 
straightened  by  pulling  the  auricle  outward  and 
backward.  But  great  danger  to  life  as  well  as  to 
hearing  may  be  caused  by  injudicious  and  panicky 
efforts  to  extract  these  intruders.  Most  of  the  cases 
that  come  to  the  physician  have  been  seriously  com- 
plicated by  meddling;  and  if  he  makes  good  use  of 
syringing  without  obtaining  an  early  success  and 
advises  delay,  another  and  more  active  operator 
is  likely  to  be  sought.  Too  often  some  form  of 
forceps  is  introduced  into  the  canal  in  hope  of  with- 
drawing the  foreign  body,  and  it  is  pressed  deeper 
and  wedged  in  the  bony  canal  or  actually  driven 
through  the  drum-head  into  the  tympanic  cavity.  At 
times,  like  damage  is  done  when  no  foreign  body  is 
present — the  wrong  ear  being  worked  at  or  the  object 
having  already  fallen  out  unnoticed.  No  examina- 
tion or  operation  should  be  undertaken  without  good 
illumination;  and  it  sometimes  suffices  to  let  the  light 
fall  in  past  the  examiner's  brow  while  the  canal  is 
straightened  by  pulling  the  ear  upward,  backward, 
and  outward,  in  order  to  give  a  good  view.  It  should 
be  clearly  and  positively  borne  in  mind  that  foreign 
bodies  seldom  cause  serious  harm,  even  if  remaining 
for  years,  unless  they  furnish  an  excuse  for  harmful 


SLIGHT  ITCHING  AND   IRRITATION  OF  CANAL.    1 47 

interference,  and  we  may  look  for  few  of  tlie  bad 
results  that  have  been  disgracefully  frequent  in  the 
past.  Rotary  rubbing  in  front  of  the  ear  while  it  is 
turned  downward  will  permit  many  a  small  body  to 
fall  out  promptly.  Any  other  measures  besides  this 
and  careful  syringing  should  be  entrusted  only  to  the 
expert;  for  when  the  foreign  body  is  really  wedged 
fast,  it  is  at  times  a  safer  and  simpler  measure  to 
remove  it  by  cutting  the  soft  parts  loose  and  turning 
them  out  of  the  way,  than  to  probe  blindly  in  a 
narrow,  swollen  canal  in  which  terrible  damage  may 
easily  be  done  unseen. 

Slight  itching  and  Irritation  of  the  canal  are 
very  common,  and  may  occur  with  or  without  distinct 
eczema,  perhaps  of  gouty  origin.  They  are  important 
as  giving  occasion  to  the  thrusting  of  objects  into  the 
ear  to  scratch  it,  or  to  the  dropping  in  of  oil  or  other 
fluids.  Such  measures  are  likely  to  aggravate  the  con- 
dition; and  any  break  of  the  surface  is  easily  infected, 
and  causes  a  boil  or  perhaps  a  long  series  of  such  ab- 
scesses. These  may  be  terribly  painful  and  exhaust- 
ing, but  are  rarely  serious  to  life  or  hearing;  yet  they 
are  easily  confounded  with  the  serious  conditions  of 
pus  in  the  middle  ear  and  may  cause  needless  alarm. 
Douching  with  pure  water  as  hot  as  can  be  borne  may 
assuage  and  perhaps  quickly  terminate  those  already 
present;  but  skilful  care  is  needed  to  cut  short  the 
rather  probable  series  of  such  boils,  as  gland  after 
gland  becomes  affected.  Deep  extension  of  the  in- 
flammation may  involve  the  periosteum  covering  the 
bony  wall,  and  not  only  may  the  swelling  press  for- 
ward the  auricle  and  simulate  an  abscess  of  the  mas- 
toid, but  the  nutrition  of  the  bone  may  be  injured 


148  THE  EAR. 

and  its  decay  ensue,  possibly  with  penetration  of  the 
process  into  the  deep  structures.  Such  an  infection, 
although  "only  a  boil,"  is  not  to  be  lightly  re- 
garded. 

Whether  the  presence  of  invisible  germs  is  the 
cause  or  only  a  consequence  of  such  affections,  long 
experience  has  shown  the  high  value  of  remedies  in- 
imical to  such  life;  and  we  note  at  times  as  the  result 
of  improper  conditions  a  growth  of  mould  inside  the 
ear.  The  diffused  inflammation,  with  its  heat  and 
moisture,  is  probably  first  present  to  furnish  a  favor- 
able site  for  such  growths;  but  they  certainly  tend  to 
keep  up  such  a  condition  by  their  presence.  The 
precise  aspergillus  or  penicillium  present  is  rather  a 
botanical  than  a  hygienic  matter;  although  the  occupa- 
tion and  surroundings  of  patients  doubtless  have  in- 
fluence in  making  them  liable  to  such  implanting  of 
one  or  another  form.  The  growths  do  not  occur  in 
healthy  ears,  and  will  disappear  as  soon  as  dryness  and 
more  normal  conditions  have  been  secured.  Drop- 
ping of  oil  or  other  fluids  into  the  ear  may  not  have 
been  so  distinctly  responsible  for  such  growths  as 
some  claim,  but  it  is  surely  not  the  best  way  to  com- 
bat such  conditions  when  present. 

Overgrowth  of  the  bony  wall  of  the  canal  is  a 
curious  condition — fortunately  rare — and  one  or  more 
of  the  bony  knobs  may  encroach  on  the  passage- 
way. These  may  be  broad-based  and  ill-defined,  or 
form  tumors  with  narrow,  stalk-like  attachments; 
hence  their  division  into  hyperostoses  and  exostoses 
respectively.  Often  there  is  a  discharge  from  the  mid- 
dle ear,  which  affords  by  its  irritation  of  the  surface 
some  explanation  of  the  growth  and  greatly  enhances 


THE   DRUM-MEMBRANE. 


149 


its  seriousness.  There  is  little  likelihood  that  such  a 
bony  mass  will  close  the  canal  so  that  sound-waves 
cannot  enter;  but  it  may  readily  interfere  with 
due  exit  of  discharge  and  lead  to  the  most  serious 
consequences.  In  many  of  the  cases  the  cause  is 
quite  doubtful,  but  the  fact  that  it  is  far  more  common 
in  the  upper-class  Englishmen  than  in  any  other  peo- 


PlG.  33. — The  drum-membrane  and  ossicles  from  within,  showing  attach- 
ment of  malleus-handle  to  drum-head,  the  insertion  of  the  tensor  tendon 
below  the  chorda,  the  axis  of  rotation  through  the  gracilis  process  and  the 
posterior  ligament  of  the  incus,  and  the  tooth  of  its  articulation  with  the 
malleus  head. 

pie  (unless  the  semi-amphibious  Sandwich  Islanders) 
points  to  bathing  as  a  rather  likely  factor  in  its 
production. 

The  Drum-membrane. — At  the  bottom  of  the 
external  canal  is  stretched  a  thin,  tense  membrane — 
the  tympanic  membrane,  or  the  drum-head  (Fig.  33) — 


150  THE  EAR. 

which  separates  the  external  from  the  middle  ear.  It  is 
very  oblique  in  position;  its  lower  margin  is  farther 
from  the  outside  than  its  upper,  and  the  forward  is 
deeper  than  the  back  part — so  it  could  be  called  quite 
accurately  the  lower  rather  than  the  outer  wall  of  the 
drum-cavity.  The  outer  layer  of  the  drum-head  is 
continuous  with  the  skin-lining  of  the  canal  and 
really  belongs  to  it  clinically;  but  in  most  respects  it 
is  considered  with  the  middle  ear,  which  it  bounds. 
Its  function  is  largely  protective,  although  it  also 
serves  as  a  receiver  for  sound-waves  and  aids  in  con- 
veying them  to  the  internal  ear  through  the  chain  of 
little  ear-bones  (ossicles)  connected  with  it;  but  an 
opening  in  it,  or  even  its  total  loss,  may  hardly  im- 
pair the  hearing  to  a  recognizable  degree.  lyow  tones 
will  perhaps  be  heard  less  distinctly,  but  high  tones 
rather  better  for  its  absence.  The  old  impression 
that  hearing  depends  upon  the  drum-head  is  ex- 
ploded; yet  its  removal,  even  when  it  has  become  an 
obstacle  to  hearing,  has  not  often  proved  a  judicious 
measure.  The  eyelids  are  not  essential  to  perfect 
sight,  yet  they  are  very  important  to  its  safety ;  just  so 
the  drum-head  shuts  out  many  hurtful  influences  and 
helps  to  maintain  a  moist,  pliable  condition  of  the 
important  parts  within  it.  The  handle  of  the  tiny 
hammer-bone  (malleus)  is  encased  in  the  upper  part 
of  the  drum-head  and  reaches  down  to  its  middle.  The 
membrane  is  kept  stretched  tightly  inward,  and  the 
shallow  funnel  shape  thus  given  adapts  it  to  respond 
to  a  very  wide  range  of  vibrations.  The  slight 
thickening  due  to  age  causes  it  to  vibrate  less  per- 
fectly and  to  impede  the  penetration  of  high-pitched 


'V/ A' '/ ■//'/( •/./ /,    /'.// R  PR UMSr  1 5  I 

sound-waves;  and  disease-changes  may  act  similarly 
and  mncli  worse  at  any  period  of  life. 

The  drum-head  may  be  torn  by  the  penetration 
of  twigs,  hair-pins,  toothpicks,  etc.,  stuck  into  the 
ear;  or  it  may  be  split  by  explosions  or  a  severe 
box  on  the  ear.  DeafnevSS  may  be  extreme  after 
such  accidents,  but  it  is  the  result  of  the  concussion 
of  the  recipient  apparatus  beyond  the  drum-head,  and 
it  may  persist  after  prompt  and  perfect  healing  of  any 
rents.  Most  patients  with  discharge  from  the  ear  have 
an  opening  in  the  drum-head,  yet  may  have  practi- 
cally unaffected  hearing,  and  such  "holes  in  the 
drum"  are  by  no  means  the  death-warrant  of  the 
function  whether  the  perforation  closes  or  not.  Loss 
or  change. of  the  drum-head  may  give  occasion  for 
the  employment  of  an  "artificial  ear-drum;"  but, 
as  a  rule,  only  for  its  effect  in  tightening  relaxed  por- 
tions of  the  conducting-apparatus.  Such  an  appa- 
ratus has  its  parallel  in  the  bridge  of  a  violin  rather 
than  in  the  head  of  a  drum.  Most  of  the  much 
lauded  patent  "ear-drums"  are  inferior  to  a  little 
pellet  of  cotton,  which  is  so  placed  that  its  press- 
ure will  tune  up  the  mechanism  without  too  much 
irritation.  However,  all  artificial  ear-drums  gener- 
ally irritate,  and  after  short  use  are  advantageously 
discarded  with  retention  of  any  gain  in  hearing. 
Most  of  the  advertisements  in  conflict  with  this  state- 
ment are  false  and  misleading.  As  the  proportion  is 
small  of  cases  of  deafness  in  which  such  laxness  of 
tissue  is  at  fault,  the  field  of  usefulness  of  artificial 
ear-drums  is  very  narrow;  and,  like  anv  other  foreign 
body  thrust  in  the  ear,  they  may  cause  much  irritation 
or  damasfe  even  in  cases  needino-  them. 


152  THE   EAR. 

Injuries  to  the  Drum-membrane. — Some  of  the 
less  sharp  but  rather  more  persistent  earaches  are  of 
merely  mechanical  origin  and  due  to  preponderance 
of  atmospheric  pressure  on  the  outside  of  the  drum- 
head when  there  is  lowered  pressure  within.  They 
are  comparable  to  that  due  to  diving  into  deep  water 
or  entering  the  compressed  air  of  a  caisson.  In  the 
latter  case  swallowing,  or  yawning,  or  Valsalva  infla- 
tion equalizes  the  pressure  (as  can  hardly  be  done  by 
the  diver),  and  precautions  of  this  sort  must  be  care- 
fully taken  in  the  air-lock  on  both  entering  and  leav- 
ing the  caisson.  The  healthy  ear-drum  can  bear  a 
pressure  on  either  surface  of  some  fifteen  pounds  to 
the  square  inch,  but  more  than  this  will  probably 
rupture  it,  while  much  less  may  give  severe  pain  and 
cause  inflammation.  When  weakened  by  disease, 
small  pressure  may  rupture  the  membrane,  and  not 
only  explosions,  but  a  box  or  other  tap  on  the  ear 
may  have  such  a  result.  So  too  even  the  slight  suc- 
tion of  a  kiss  on  the  ear  has  been  credited  with  rupt- 
uring the  drum-head,  and  to  almost  all  persons  such 
a  demonstration  is  very  painful.  It  is  also  possible 
that  inflation  by  the  Valsalva  or  Politzer  method  may 
burst  the  drum-head  from  within;  and  violent  cough- 
ing, as  in  whooping-cough,  often  causes  breaking  of 
small  blood-vessels  or  even  tearing  of  the  tympanic 
membrane.  Such  shocks  as  are  experienced  in  violent 
falls  may  rupture  the  drum-head.  This  is  frequent 
in  fractures  of  the  base  of  the  skull,  and  the  flow  of 
blood  from  the  ear  is  often  taken  as  proving  a  serious 
and  probably  fatal  injury;  yet  the  tear  may  be  inde- 
pendent of  fracture,  and  may  be  from  the  wall  of  the 
canal   without   severe  injury  to  the   bone.     In  rare 


DISEASE    OE    'J7/E   DRUM  MEMBRANE.  [53 

cases  a  fall  upon  the  chin  may  drive  the  lower  jaw 
back  into  the  ear-canal  and  canse  any  of  the  previous 
symptoms.  Non-interference  and  mere  protection 
should  be  the  rule  in  all  such  injuries.  vSyrin(,nng 
and  instillations  are  usually  uncalled  for,  and  are 
likely  to  do  harm,  and  the  expert  aurist  intervenes 
only  for  clear  cause.  'Such  a  rupture  of  the  drum- 
head will  usually  heal  after  a  time,  even  though  it 
shows  no  early  promise  of  such  repair,  and  the  aurist 
has  at  command  means  to  secure  this  when  it  would 
otherwise  be  doubtful. 

Disease  of  the  Drum-membrane. — Most  of  the 
ruptures  of  the  drum-head  are  due  to  the  outbreak  of 
fluid  from  within ;  and  while  some  of  these  are  mere 
pressings  aside  of  the  fibers,  which  close  again  without 
scar,  others  take  place  only  after  so  much  ulcerative 
destruction  that  a  considerable  perforation  is  made  or 
the  whole  membrane  may  be  destroyed.  Healing 
after -the  loss  of  tissue  entails  new  scar-tissue,  which 
is  generally  recognizable  by  its  thinness  and  is  likely 
to  stretch  and  sag  out  of  the  plane  of  the  rest  of  the 
drum-head.  As  has  been  said,  it  was  formerly  thought 
that  the  drum-head  was  very  essential  to  hearing, 
and  that  perforations  in  it  never  healed,  but  entailed 
permanent  defect  or  loss  of  hearing.  On  the  con- 
trary, we  now  know  that  it  may  be  destroyed  by 
disease  or  removed  by  the  surgeon  with  little  im- 
pairment of  the  hearing,  and  that  large  openings 
may  close  nicely  even  after  they  have  been 
present  for  years.  The  cutting  away  of  the  entire 
drum-membrane  is  followed  by  its  renewal  in  many 
cases,  and  without  its  destruction  w^e  sometimes 
find  a  membrane  not  unlike  the  drum-head  formed 


154 


THE   EAR. 


across  the  canal  external  to  the  real  membrane.  The 
protective  function  of  the  membrane  is  very  impor- 
tant, and  we  usually  desire  its  repair  in  every  case 
even  although  it  may  prove  rather  an  impediment 
than  an  aid  to  hearing.  Many  operations  have  been 
done  to  remove  it  wholly  or  in  part  when  its  changes 
make  it  an  obstacle  to  the  access  of  sound-waves;  but 
these  have  generally  failed  because  of  its  regrowth,  or 
when  successful  in  securing  a  permanent  opening 
they  have  been  followed  in  a  year  or  two  by  a  loss  of  all 
the  gain  in  hearing  and  generally  of  what  was  before 
possessed.  Such  operations  have,  therefore,  been 
generally  abandoned.  When  the  drum-head  is  open 
the  cavity  within  is  likely  to  become  too  dry  for  the 
best  hearing,  while  it  is  constantly  liable  to  irritation 
from  the  entrance  of  water  or  dust,  with  lighting-up 
of  severe  inflammation.  All  of  these  inflammations 
have  danger,  for  extension  may  easily  take  place  to 
adjacent  important  structures,  and  fatal  meningitis, 
brain-abscess,  or  general  blood-poisoning  may  ensue. 
One  of  the  curious  and  pernicious  conditions  fre- 
quently met  is  a  tendency  to  grafting  of  skin-flakes 
from  the  outside  of  the  drum-head  upon  the  succulent 
lining  of  the  middle-ear  cavities.  Here  their  ex- 
traordinary power  of  growth  is  increased  by  unusual 
food-supply,  and  the  cavity  becomes  lined  with  skin, 
which  sheds  rapidly,  layer  upon  layer,  imtil  onion- 
like masses  of  cholesteatoma  are  formed.  These 
may  provoke  suppuration  as  an  effort  of  nature  to  soften 
and  break  them  down,  and  by  pressure  they  cause 
absorption  or  destruction  of  the  bony  surroundings, 
opening  a  way  for  escape — outward,  perhaps,  but  too 
often  inward  upon  the  brain.     Many,    if  not   most, 


TIIK   MJJ)])LK   EAR.  I55 

cases  of  persistent  or  recurrent  ear-discharges  are 
complicated  and  pro])ably  caused  by  such  cholestea- 
tomatous  collections. 

THE  MIDDLE   EAR. 

The  middle  ear,  which  lies  beyond  the  drum-head, 
is  the  seat  of  two-thirds  of  all  aural  troubles,  and  as 
some  of  its  affections  are  of  the  utmost  danger  to  life 
as  well  as  to  hearing,  its  health  is  proportionally  still 
more  important.  It  is  by  no  means  so  limited  in  ex- 
tent as  often  considered,  for  the  drum-head  forms  the 
lower,  outer  wall  of  only  one  portion  of  the  drum- 
cavity;  while  the  Eustachian  tube,  extending  forward 
an  inch  or  more  to  connect  it  with  the  upper  part  of 
the  throat,  and  the  air-cells,  which  extend  back- 
ward into  the  mastoid  region  (and  may  also  penetrate 
every  portion  of  the  temporal  bone),  are  equally  por- 
tions of  the  middle  ear.  It  is  a  part  of  the  upper  air- 
passages,  very  complex,  and  not  easily  affected 
throughout  by  their  diseases,  but  as  likely  to  be  in- 
volved as  any  of  the  accessory  cavities  of  the  nose; 
while  the  intricacy  of  the  field  or  the  extreme  delicacy 
of  some  portions  makes  persistence  of  the  trouble 
very  probable.  Hence  it  has  been  calculated  that 
at  least  one-third  of  all  our  adult  population  are 
notably  deaf  in  one  or  both  ears.  The  census  informs 
us  that  no  less  than  700  per  million  are  dumb  as  the 
result  of  deafness,  but  these  represent  only  a  small 
group  who  lost  their  hearing  before  they  had  fully 
acquired  speech. 

The  middle  ear  is  an  intricate  air-space  developed 
outward  from  that  portion  of  the  air-passages  where 
nose  and  throat  meet.     At  this  point  is  the  trumpet- 


156 


THE  EAR. 


mouth  of  the  Eustachian  tube  (Fig.  34) — above  the 
soft  palate,  but  in  close  relation  to  the  tonsil-masses  on 
each  side  of  the  back  of  the  mouth  and  to  the  more 
important  tonsil  in  the  vault  above  the  palate.  On 
account  of  the  influence  of  nasal  disease  on  the  ear 
much  of  the  real  hygiene  of  the  ear  is  considered  in 
the  preceding  chapter.  The  whole  middle  ear  is  lined 
with  mucous  membrane  absolutely  continuous  with 
that  in  the  nose  and  throat,  and,  like  it,  having  its 
effete  cells  melt  down  into  sticky  mucus  instead  of 


Jtoofof  Tp/npanum- 


.„      ., .  .     ,    x'iswa™,/    .EustachSanlSiie 

■  of  Bona  Meatus    \  I      i     ^^S-k  \ 

•>  .  I      ,       \.-<ms^m  I     laidopen 

Fig.  34. — Frontal  section  of  the  organ  of  hearing  (modified  from  Politzer). 

shedding  off  as  scales.  Much  of  the  epithelium  is 
furnished  with  cilia  to  sweep  this  fluid  on  into  the 
throat,  so  the  Eustachian  tube  is  very  important  as  a 
drainage-canal;  but  its  ventilating  function  should 
receive  equal  consideration.  This  drum-head,  like 
the   martial   instrument,   must  have  a  side  opening 


COMMON  CAUSES    OF  DEAFNESS.  I  57 

through  which  air-pressure  may  be  maiutaiucd  equal 
ou  both  sides  of  the  drum-head  if  it  is  riglitly  to  per- 
form its  part.  If  this  aperture  is  closed,  uot  ouly  will 
the  souuds  uuuaturally  reverberate  witliiu,  but  the  air 
will  be  absorbed  by  the  uioist  walls  aud  the  partial 
vacuum  will  affect  the  ill-supported  druui-uiembraue 
and  other  structures.  Prej^onderatiug  outside  press- 
ure will  force  in  the  drum-head,  rendering  it  unduly 
tense  or  stretching  it  out  of  shape.  The  stapes  at 
the  end  of  the  chain  of  ossicles  will  be  pressed  too 
much  upon  the  labyrinth,  causing  deafness,  dizziness, 
and  subjective  noises;  and  there  will  be  a  tendency  to 
undue  congestion  and  oversecretion  in  response  to  the 
lessened  air-pressure.  Normally  every  act  of  swal- 
lowing, yawning,  etc.,  opens  the  tubes  and  gives  a 
chance  for  equalization  of  intratympanic  pressure,  for 
the  palate-muscles  act  as  dilators  of  the  tube;  but  a 
stopped-up  nose  reverses  the  process  and  then,  if  the 
tubes  are  not  likewise  stopped,  every  swallowing 
motion  draws  air  out  of  the  ears. 

In  the  foregoing  we  face  at  once  the  causes  of 
most  cases  of  deafness,  and  it  is  probable  that 
hereditary  influence,  such  as  is  .  often  cited,  lies 
really  in  an  inherited  configuration  of  the  nose, 
or  a  tendency  to  catarrhal  aflfections  of  its  mucous 
membranes.  Every  "cold-in-the-head"  tends  in  one 
of  the  ways  above  mentioned  mechanically  to  involve 
the  ears,  even  if  no  continuation  of  the  process  act- 
ually invades  the  tympanic  cavity;  and  while  the  re- 
covery may  seem  complete,  there  is  likely  to  be  some 
unrelieved  remnant  of  trouble  insidiously  but  steadily 
increasing,  and  first  one  ear  and  then  the  other  shows 
the  decrease  in  hearing.     The  deafness  may  be  quite 


158  THE   EAR. 

marked  at  the  onset  if  the  involvement  is  considerable, 
and  may  be  far  from  totally  relieved,  although  greatly 
better  as  the  attack  passes  off;  yet  if  only  one  ear  is 
impaired  the  condition  may  progress  extensively 
before  the  patient  is  ready  to  believe  that  anything  is 
really  wrong.  It  was  computed  by  von  Troeltsch 
that  one-third  of  all  adults  are  deaf  to  considerable 
degree  in  one  or  both  ears;  and  all  later  students  ac- 
cept this  as  a  fair  estimate.  Examinations  in  the 
schools  show  only  a  less  degree  of  trouble  but  a  most 
threatening  array  of  beginning  cases,  with  disability 
of  one  ear  in  10  per  cent,  and  of  both  ears  in  5  per 
cent,  even  of  young  children. 

The  aspect  grows  much  more  serious  when  we 
consider  the  inflammatory  involvements  which  often 
accompany  the  eruptive  diseases,  especially  scarlet 
fever  and  measles,  but  also  typhoid  fever  and  small- 
pox, and  probably  in  the  worst  form  in  diphtheria. 
In  such  cases  the  physician  is  usually  in  attend- 
ance, and  may  be  driven  to  vigorous  action;  yet  too 
often  the  gravity  of  the  general  condition  leads  to 
overlooking  or  underrating  the  ear-affection,  and  ir- 
remediable conditions  develop  that  certainly  ought  to 
have  been  foreseen  and  combated.  It  may  be  unfair 
to  ascribe  bad  results  solely  to  neglect,  since  the  best 
treatment  is  not  always  of  avail;  but  it  is  surely  in- 
judicious to  leave  untried  the  simple  measures  which 
may  save  the  hearing,  or  even  the  life,  on  the  as- 
sumption that  the  patient  is  too  sick  to  be  thus 
troubled. 

The  suppurative  diseases  of  the  tympanic 
cavities  call  for  much  more  than  hygiene,  but  this 
has  a  place  in  reducing  the  probabilities  of  serious 


DECA  Y  OF  THE  BON  Y  S'l'RUCTURKS  OJ'  -JllJi  EAK.    1  59 

outcome  and  in  making  the  condition  less  offensive 
to  neighbors.  Cleansing  is  tlie  first  and  some- 
times the  only  requisite  in  abating  or  curing  these 
conditions,  and  should  be  most  faithfully  carried  out, 
tinder  medical  direction  if  possible.  Odor,  sometimes 
such  as  to  make  the  sufferer  intolerable  to  those  about 
him,  is  not  an  infrequent  penalty  of  incomplete  clean- 
liness; and  while  full  success  may  be  possible  even  to 
the  expert  only  after  operative  laying  open  of  the 
cavities  to  secure  better  access,  mitigation  can  gener- 
ally be  secured  in  the  worst  cases.  lyife-insurance 
companies  generally  refuse  to  insure  those  with  dis- 
charging ears,  knowing  that  the  risk  is  a  very  real 
one,  and  that  serious  results  may  at  any  time  follow 
a  slight  or  unrecognizable  cause.  The  often-cited 
prediction  that  such  affections  will  "  be  outgrown  " 
if  let  alone,  and  the  falser  claim  that  it  is  dangerous 
to  check  such  discharges,  have  now  few  medical  sup- 
porters, and  the  danger  of  blocking  the  flow  is  becom- 
ing recognized  as  utterly  different  from  the  policy  of 
lessening  or  terminating  its  formation.  People  are 
learning  that  when  an  otorrhea  stops  spontaneously — 
as  when  the  rash  in  measles  or  scarlatina  "strikes 
in" — it  is  the  result  and  not  the  cause  of  serious 
trouble  lighting  up  in  deeper  structures. 

Decay  of  the  bony  structures  of  the  ear  is  very 
prone  to  render  obstinate  and  protracted  the  other 
features  of  the  case,  but  modern  aural  surgery  has 
taught  physicians  to  cut  promptly  and  with  fair  safety 
many  a  knot  that  until  recentlj'  was  beyond  disen- 
tangling. 

General  ill-health  is  a  most  serious  factor  in  main- 
taining these  rebellious  aflfectious;  but  they  are,  on 


l60  THE.  EAR. 

the  other  hand,  frequent  causes  of  debility  or  general 
disease.  Not  a  few  of  the  ear-inflammations  of  early- 
life  are  tubercular  in  their  nature,  and  may  give  rise 
to  infected  neck-glands  first  and  to  consumption  of 
the  lungs  or  other  organs  later.  Too  conservative  a 
success  in  securing  absorption  of  such  deposits  may 
later  prove  in  reality  the  most  disastrous  of  failures. 
The  ear-symptoms  of  these  attacks  are  not  always 
well  marked,  and  the  case  may  resemble  one  of 
typhoid  fever  or  meningitis,  in  the  course  of  which 
the  appearance  of  an  ear-discharge  will  be  unnoted  or 
ignored.  It  is  the  physician's  duty  to  search  for 
aural  disease  in  all  doubtful  cases  without  waiting  for 
it  to  force  itself  upon  the  attention,  and  as  soon  as 
recognized  to  treat  it  vigorously  even  if  there  is  little 
likelihood  of  a  dangerous  result.  Until  this  care  is 
commonly  observed  there  will  be  far  too  many  deaths 
and  disablements  ascribed  to  meningitis  of  unknown 
origin. 

Earache. — More  within  the  scope  of  this  work  are 
the  cases  of  ear-inflammation  arising  from  "cold," 
and  generally  known  as  "earaches."  The  common 
assumption  that  they  are  mere  neuralgias  is  upset  in 
nearly  every  case  carefully  examined.  The  affected 
drum-head  is  visibly  congested,  often  distended  by 
the  secretions  within,  and  pressure  in  front  of  the  ear 
almost  always  reveals  tenderness  which  is  fairly 
characteristic.  The  dropping  in  of  sweet  oil  and  laud- 
anum will  probably  be  continued  in  spite  of  all  that 
shall  ever  be  written  or  said  against  it,  and  roasted 
onions  and  hosts  of  similar  substances  will  be  em- 
ployed to  the  end  of  time.  "  Ear-drops"  in  count- 
less variety   have    been    commended    as    infallible, 


EARACHE.  l6l 

and  the  last  one  employed  before  relief  (perhaps  in 
spite  of  it)  gets  the  eredit  of  a  cnre.  Not  only  is  all 
of  this  nnscientific,  bnt  it  is  very  irrational.  Kxani- 
ination  alone  ean  determine  the  form  and  grade  of 
the  affection.  It  is  sometimes  a  mere  boil  of  the 
canal,  dne  in  part  to  scratching  or  other  accidental 
infection,  with  no  danger  beyond  the  temporary  pain 
and  stopjDage  or  perhaps  recurrence  of  the  infection. 

More  often  the  pain  is  due  to  a  serous  catarrh  of 
the  tympanum,  and  will  yield  only  with  the  out- 
break through  the  drum-head  of  the  pent-up  secre- 
tion. Few  children  escape  attacks  of  this  sort,  and 
the  evidence  remains  in  a  minute  perforation  or  scars 
in  so  large  a  number  that  some  anatomists  have  be- 
lieved this  to  be  a  normal  feature  of  the  upper  mar- 
gin of  the  drum-head.  Yet  such  a  condition  is  prac- 
tically unknown  in  infancy,  is  found  increasingly  fre- 
quent throughout  childhood,  and  is  present  in  25  per 
cent,  of  all  adult  drum-heads,  excluding  the  cases 
in  which  there  was  recognized  discharge.  There 
may  have  been  no  discharge  or  "  running  at  the  ear." 
One  or  two  drops  of  pus  which  were  forced  through 
the  drum-head  may  not  have  reached  the  outside  or 
may  have  mixed  unrecognized  with  the  fluids  dropped 
into  the  ear;  or  the  sudden  relief  which  commonly 
marks  these  cases  may  have  been  gained  by  opening 
of  the  Eustachian  tube,  allowing  exit  in  that  direc- 
tion. Sometimes  the  brunt  of  the  affection  has  fallen 
upon  the  drum-head  alone,  and  small  blisters  or 
pustules  on  its  surface  have  caused  brief  suffering 
with  little  deafness  or  danger.  Cold  air  or  cold  water 
entering  the  canal  may  be  responsible  for  such  a  con- 
dition; but  usually  these  act  through  the  Eustachian 
11 


1 62  '  THE  EAR. 

tube,  and  the  condition  is  truly  middle-ear  inflamma- 
tion. Few  of  the  patients  getting  "water  in  the 
ear,"  especially  when  knocked  about  by  a  breaker, 
would  have  been  helped  by  plugging  the  outside  ear. 
It  has  been  water  in  the  nose  acting  upon  or  through 
the  Eustachian  tube  which  has  wrought  the  mis- 
chief, the  choking  or  nose-blowing  having  helped  to 
carry  the  fluid  where  it  could  irritate.  Any  liquid  in 
the  drum-cavity  has  usually  formed  there  as  a  serous 
exudation,  for  it  is  very  hard  even  intentionally  to 
carry  fluid  all  the  way  up  from  the  nasopharynx. 
Any  one  who  blows  the  nose  after  spraying  it  or 
otherwise  introducing  fluid  can  hear  the  bubbling 
in  the  tube-mouth,  and  can  realize  the  importance 
of  draining  away  all  such  fluid  before  blowing.  Care- 
lessness as  to  this  or  in  using  too  much  pressure  has 
brought  "the  dangerous  nasal  douche"  into  dis- 
repute among  all  aurists,  and  made  them  view  with 
suspicion  many  other  methods  of  washing  the  nasal 
cavities.  If  employing  watery  fluids  otherwise  than 
in  spray,  only  the  narrower  side  of  a  fairly  free  nose 
should  receive  the  fluid,  which  is  allowed  to  escape 
from  the  wider  side.  The  pressure  should  be  but 
slight,  and  when  the  gravity  douche  is  used  the  level 
of  its  fluid  should  not  be  above  the  brow.  There 
must  be  as.  complete  draining  away  of  the  fluid  as 
possible  before  blowing  the  nose. 

In  all  cases  of  the  exanthematous  diseases  in  which 
the  ears  are  usually  in  peril,  as  well  as  in  all  that 
show  earache,  protection  counts  for  much  in  ward- 
ing off"  evil;  and  the  old-fashioned  night-cap  may 
be  worn  with  great  advantage.  A  mere  flake  or 
plug  of  cotton  in  the  ear  is  as  likely  to  do  harm  as 


EARACHE.  163 

good,  for  it  is  rather  the  ear-region  than  tlie  canal 
alone  that  needs  protection  in  bed.  One  side  of  the 
head  is  for  a  while  buried  in  the  pillow  and  perhaps 
rather  macerated  by  perspiration,  and  is  then  turned 
up  unprotected  to  the  cool  air  and  evaporation,  with 
a  probable  reduction  of  40°  in  temperature  in  a  few 
minutes.  It  is  small  wonder  that  an  ear  that  has 
struggled  against  inflammatory  influences  during  the 
day  will  light  up  to  acute  pain  an  hour  or  two  after 
bed-time,  as  is  the  usual  history  of  these  cases.  The 
night-cap  may  then  give  little  relief,  but  is  potent  to 
forestall  such  attacks  on  subsequent  nights.  The  re- 
lief of  such  earaches  properly  belongs  to  medicine 
rather  than  to  hygiene,  but  it  should  be  better  known 
generally  that  heat  is  the  most  valuable  single 
remedy.  Most  of  the  "ear-drops"  merely  serve  as 
means  of  conveying  heat  to  the  inflamed  parts,  and 
pure  water  can  do  this  better  than  any  other  means. 
It  is  usually  difficult  to  persuade  people  that  a  remedy 
so  universally  at  hand  as  hot  water  is  to  be  preferred 
to  the  host  of  less  available  and  less  harmless  "  cures;" 
yet  one  has  but  to  try  the  hot-water  bottle  exter- 
nally, and  gentle  douching  or  simple  pouring  of  hot 
water  into  the  upturned  ear,  to  find  how  grateful  it 
generally  proves.  Severe  inflammations  are  not  cured 
at  once  by  this  or  any  other  means.  Vigorous  leech- 
ing in  the  early  stages  is  commonly  held  to  be  even 
more  efficacious  if  available;  but  hot  douching  tends 
to  relieve  pain  by  reducing  the  inflammation,  and  it 
is  safe  at  all  stages  and  serves  to  cleanse  the  canal  of 
any  undesirable  material,  such  as  wax,  skin-flakes,  or 
microbes.  It  must,  of  course,  be  free  from  contami- 
nation itself.     Boiled  water,  chilled  to  a  bearable  heat 


164  THE  EAR. 

and  used  with  a  well-scalded  syringe  or  other  means, 
will  probably  never  do  the  slightest  harm.  The  ear 
should  be  dried  as  well  as  possible  after  its  use,  as 
well  as  protected  from  external  influences,  the  cover- 
ing being  reinforced  by  cotton  or  wool  as  required. 
Bodily  activity  or  general  temperature-changes  may 
greatly  aggravate  the  pain,  so  rest,  especially  in  bed, 
with  light  diet  is  to  be  strongly  urged.  Soft  food  is 
usually  requisite,  since  every  chewing  effort  gives 
pain;  and  constipation  or  any  other  cause  of  head- 
congestion  should  be  relieved  if  possible.  Each  case 
of  this  kind  must  be  treated  as  the  amenable  initial 
stage  of  what  may  prove  a  serious  or  even  fatal  mal- 
ady, and  no  pains  should  be  spared  to  relieve  it. 

THE   INTERNAL   EAR. 

In  some  cases  of  middle-ear  involvement  there 
occurs,  early  or  late,  an  implication  of  the  internal  ear. 
This  may  be  a  direct  extension  of  the  inflammatory 
process  with  rapid  destruction,  or  it  may  follow  upon 
incapacitation  of  the  conductive  apparatus  and  at- 
rophy through  disuse  of  the  percipient  apparatus 
beyond.  In  certain  constitutional  diseases  an  over- 
whelming dose  of  the  poison  may  fall  upon  the  nerves 
of  hearing  without  other  symptoms  of  ear-involve- 
ment. Mumps,  more  rarely  diphtheria,  but  most 
often  syphilis,  inherited  or  acquired,  may  produce 
marked  or  total  deafness;  and  meningitis  of  the  epi- 
demic or  other  types  would  often  leave  deafness  if  so 
many  of  its  victims  did  not  succumb.  In  many  of 
these  cases  tonic  medication  promoting  the  absorption 
of  inflammatory  products  may  rescue  .the  hearing 
more  or  less  completely;  and  in  every  case  in  which 


"NOISES  IN   rilR   EAR."  1 65 

there  is  reason  to  suspect,  from  the  stigmata  of  syph- 
ilis or  from  the  mere  absence  of  local  disease,  that  the 
nervous  apparatus  is  at  fault,  such  medication  should 
be  given  full  trial. 

The  term  "  nerve-deafness  "  was  once  a  cloak  for 
ignorance  as  to  conditions  readily  shown  to  be  of  a 
different  nature;  but  this  trouble  is  now  receiving  due 
recognition   as   a   real   and   most   important   matter. 

There  are  affections  of  other  nerves  than  that  of 
hearing  connected  with  ear-disease.  The  facial 
nerve,  which  controls  the  motion  of  most  of  the  face- 
muscles,  accompanies  the  auditory  nerve  into  the  ear 
and  passes  on  through  its  substance  to  emerge  near 
the  angle  of  the  jaw.  It  is  much  exposed  to  involve- 
ment in  ear-inflammations,  although  the  latter  may 
prove  so  evanescent  as  to  leave  little  trace  by  the 
time  the  facial  palsy  becomes  well  developed. 

"Noises  in  the  Ear"  (Tinnitus  Aurium). — Quite 
as  trying  to  many  persons  as  all  the  inconveniences 
of  deafness  are  the  "noises  in  the  head"  which  often 
accompany  it.  These  may  be  of  every  character — 
roaring,  hissing,  ringing,  thumping — and  many  of 
them  may  seem  unbearable,  especially  if  constantly 
present.  The  noises  have  no  definite  relation  to  de- 
fect of  hearing,  and  may  persist  for  decades  without 
deafness  or  be  wholly  absent  while  the  hearing  is  dis- 
tinctly failing.  However,  they  are  often  enough  as- 
sociated with  deafness  to  make  them  commonly 
dreaded  as  foreshadowing  and  intensifying  that  calam- 
ity. When  we  add  that  they  sometimes  defy  all 
efforts  to  quiet  them  and  may  even  seem  to  keep 
the  patient-  awake,  it  is  small  wonder  that  they  have 
been  often  assigned  as  an  excuse  for  suicide.      Their 


1 66  THE  EAR. 

causation  is  as  varied  as  their  character.  They  are 
generally  the  expression  of  irritation  by  pressure  upon 
the  nerve-endings  in  the  labyrinth  of  the  ear;  but 
blood-changes  are  often  responsible,  and  anemia  may 
be  the  cause  as  well  as  plethora.  While  disturbed 
conditions  of  the  conducting-apparatus  are  responsible 
for  many  cases,  others  are  due  to  intracranial  irrita- 
tion, perhaps  without  the  slightest  ear-trouble.  In  a 
small  but  notable  group  of  cases  the  real  seat  of  the 
irritation  is  in  the  nose,  and  minute  examination 
shows  one  or  more  areas  of  firm  contact  of  parts 
which  ought  to  be  well  separated.  Well-directed 
treatment — shrinking,  moving,  or  removing  the  tis- 
sues concerned — will  produce  prompt  and  perhaps 
permanent  relief  In  certain  other  cases  the  general 
vascular  condition,  and  especially  overaction  of  the 
heart,  is  the  main  cause  of  the  trouble  and  must  be 
medically  treated.  In  rare  instances  there  is  a  local 
dilatation  of  an  artery,  an  aneurysm,  giving  rise  to  a 
noise  which  physician  as  well  as  patient  can  hear, 
and  which  pressure  on  the  artery  lower  down  will 
still.  Another  form  of  noise  which  bystanders  can 
hear  is  a  clicking  due  to  opening  of  the  Eustachian 
tube  when  the  soft  palate  is  lifted.  This  may  be 
very  distressing  when  there  is  spasmodic  movement 
of  this  sort  and  calls  for  active  tonic  measures. 

Tests  for  Hearing. — Much  interest  and  importance 
center  about  the  tests  of  hearing  and  the  recognition, 
estimation,  and  localization  of  its  defects.  Much  of 
the  matter  is  outside  of  the  strictly  hygienic  field, 
but  certain  broad  facts  deserve  better  comprehension*. 
The  ears  should  recognize  sounds  through  some  ten 
octaves;  so,  to  be  thorough,  testing  must  have  wide 


TESTS  FOR  HEARING.  I  67 

scope.  The  watch,  often  used  as  a  test,  has  an  im- 
pure, high  sound  of  little  practical  value,  since  it  may 
be  well  heard  by  very  deaf  ears  or  poorly  by  these 
perfect  for  all  other  tones.  The  voice  is  far  more 
practical,  since  it  has  a  wide  range  of  pitch — perhaps 
from  100  to  5000  vibrations  per  second — and  can  be 
used  in  very  varying  volume.  A  faint  whisper  should 
be  audible  for  %  meter  (20  inches)  in  a  quiet  place, 
and  only  by  the  ear  directed  toward  the  speaker;  a 
stage  whisper  with  the  air  remaining  after  an  ordinary 
"tidal  expiration"  should  be  heard  15  meters  (49 
feet);  while  the  need  of  a  loud  voice,  if  not  very 
definite,  still  serves  to  mark  extreme  deafness.  Tun- 
ing-forks of  various  pitch  are  good  quantitative  tests, 
and  they  enable  us  to  compare  the  hearing  through 
air  and  through  the  bones  of  the  head,  and  thus  to 
learn  the  seat  of  the  trouble.  In  affections  of  the 
conducting-apparatus  hearing  for  low  tones  is  likely 
to  be  first  impaired  or  lost,  while  it  is  the  upper  scale 
that  usually  suffers  in  nerve-deafness.  So,  too,  a  fork 
may  be  heard  unduly  loud  and  long  when  resting  on 
the  head,  although  ill-heard  in  the  air  before  an  ear 
with  impaired  conducting-apparatus;  but  with  nerve- 
impairment  the  bone-conduction  suffers  more  than 
the  conduction  through  air.  Hence  a  vibrating  tun- 
ing-fork touching  the  head  in  the  middle  line  ought 
to  be  heard  louder  in  the  deafer  ear  if  the  trouble  is 
in  the  middle  or  the  external  ear;  but  worse  in  the 
deafer  ear  if  the  nerve-apparatus  is  at  fault.  Rested 
on  the  bridge  of  the  nose,  the  ears  should  hear  the 
vibrating  fork  as  long  as  the  fingers  holding  its 
handle  feel  the  vibrations;  but  the  duration  is  meas- 
urably less  when  the  nerves  are  affected,  and  greater 


1 68  THE   EAR. 

when  impairment  of  the  conducting  parts  shuts  in 
the  sound,  just  as  it  shuts  out  air- vibrations.  Thus 
by  a  series  of  tests  we  are  usually  able  to  decide  the 
amount  and  location  of  the  defect  of  hearing  and  can 
take  due  measures  for  its  relief.  It  need  hardly  be 
argued  that  deafness  due  to  a  plug  of  wax  closing  the 
canal,  or  to  fluid  poured  out  in  the  middle  ear,  or  to 
a  forcing  in  of  the  drum-head  by  preponderating  out- 
side pressure  will  not  be  relieved  by  the  same  meas- 
ures as  should  be  employed  in  cases  of  paralysis  of 
the  auditory  nerve  by  the  poison  of  syphilis  or  the 
pressure  of  a  blood-clot  or  tumor. 

Ear-Trumpets. — A  word  should  be  said  as  to  aids 
for  the  deaf.  These  are  offered  in  countless  forms 
and  with  shameless  advocacy.  Many  of  them  have 
good  points  for  the  few  cases  for  which  they  are 
suited  :  none  have  half  the  value  or  field  of  useful- 
ness claimed  by  their  inventors.  There  have  been 
mentioned  already  the  use  and  limitations  of  "ear- 
drums." Bar-trumpets  are  valuable  usually  in  direct 
proportion  to  their  size,  since  they  aid  solely  by  con- 
centrating a  greater  volume  of  sound-waves,  and  in- 
conspicuous aids  are  usually  of  little  value.  When 
the  hearing  through  the  bone  is  much  better  than 
through  the  air,  fan-like  instruments  held  to  the  teeth 
may  prove  real  helps.  Of  a  dozen  of  the  same  make 
one  or  two  trumpets  may  be  far  better  than  the  rest, 
and  the  deaf  person  should  obtain  advice  as  to  the 
kind  of  instrument  to  test  and  then  try  a  number 
of  that  form.  Such  aids  are  not  only  of  temporary 
benefit,  but  when  rightly  used  they  may  permanently 
improve  the  hearing. 


THE   HYGIENE   OF  THE   EYE. 

By   WALTER   I-.   I'YLE,  M.  D., 

OK    I'HILADELl'HIA, 

Assistant  Surgeon  to  Wills  Eye  Hospital. 


GENERAL    DESCRIPTION   OF    THE    EYEBALL  AND   ITS 
DISEASES. 

Advantages  of  Binocular  Vision. — Fortunately 
man  is  endowed  with  two  eyeballs.  Such  a  delicate 
organ  as  the  eye  is  very  susceptible  to  destruction 
of  function  from  injury  and  disease,  and  in  case  one 
eye  is  ruined  its  fellow  can  in  great  part  compensate 
for  the  loss.  The  additional  advantages  of  binocular 
vision  are  many.  There  is  a  more  accurate  estima- 
tion of  size,  depth,  distance,  direction,  and  motion, 
all  of  which  are  matters  of  gradual  education  from 
infancy  and  have  psychologic  and  physiologic  expla- 
nations which  are  not  within  the  province  of  this 
article.  Binocular  vision  also  affords  a  much  better 
field.  A  person  with  one  eye  is  handicapped  by  the 
limitations  of  vision  caused  by  the  protrusion  of  the 
nose  obscuring  objects  on  the  side  of  the  blind  eye. 

The  eyeball  resembles  in  shape  a  sphere  or  globe; 
on  the  anterior  surface  of  which  is  placed  the  segment 
of  a  smaller  sphere  (Fig.  35).  The  average  diameter 
of  the  eyeball  is  approximately  one  inch.  It  is  a 
trifle  longer  anteroposteriorly  than  vertically.  It  is 
contained   in  a  conical    cavity  formed  by  the  bones 

169 


170 


THE  EYE. 


of  the  face  and  skull,  called  the  orbit  (Fig.  36),  and 
is  supported  by  a  cushion  of  fat  and  other  tissues.     It 


Ocular  muscle 


Sclera. 
Choroid 

Ciliary  jnusclf, 
Iris_ 
Conjuiic.  cul-de-sac 
Ant.  chamber  and 

aqueous  humor_ 

Crystalline  lens 

Posterior  chamber 

Atigle  ofant.chajnbcr 

Suspensory  ligament^ 

of  the  lens 


Cornea  Vitreous  chamber 

Fig.  35. — Vertical  section  through  the  eyeball  and  eyelids. 

is   held   in   place   by   its   membranes   and    muscles, 
by  which  it   is   also   moved;   and   it   is   surrounded 

optic  foramen. 


Fig.  36. — The  bony  orbit,  showing  the  optic  foramen. 

by  a  thin  membranous   sac,    called  the  capsule  of 
Tenon.     Hence,  laterally   and   posteriorly   the   eye- 


THE  EYEBROWS.  I7I 

ball  is  well  protected  by  the  bony  orbit,  and  is 
shielded  against  shock  by  the  orbital  tissue  and  fat. 
So  important  is  the  function  of  the  fat  of  the  orbit 
that  it  is  said  to  be  the  last  to  disappear  in  emacia- 
tion from  disease  or  starvation. 

The  anatomic  conformation  of  the  skull  varies 
greatly  in  different  individuals  and  race;  and  accord- 
ing as  the  orbit  is  deeply  set  with  overhanging  ridges 
of  the  frontal  bone,  or  is  more  exposed,  there  is  a  dif- 
ferent amount  of  bony  protection  afforded  the  eyeball. 
Some  eyes  are  very  deep  set  in  the  skull,  while  others 
are  quite  protruding  and  more  liable  to  injury.  Ante- 
riorly the  eyeball  is  protected  by  the  eyebrows,  eye- 
lids, and  eyelashes. 

The  eyebrows  are  formed  of  muscle,  thickened 
skin,  and  stiff  hairs,  which  rest  over  a  bony  ridge  in 
the  front  of  the  skull  above  the  margin  of  the  orbit. 
They  are  not  seen  in  the  lower  animals.  The  func- 
tions of  the  eyebrows  are  to  protect  the  eye  from  dust 
and  perspiration,  and  to  give  shade  to  the  eye.  The 
eyebrows  have  a  marked  influence  on  facial  expres- 
sion, and  many  shades  of  emotion  are  portrayed 
by  their  movements.  In  some  persons  the  eyebrows 
are  very  scant,  in  fact  in  fair  women  they  are  some- 
times only  delicately  pencilled,  while  in  others,  for 
instance  swarthy  men,  they  are  long,  thick,  and 
bushy,  giving  a  most  ferocious  appearance,  especially 
when  unkempt.  There  is  a  tendency  for  the  hair  of 
the  eyebrows  to  become  thickened  and  tough  in  ad- 
vancing age.  Burns  of  the  eyebrow  require  the 
same  treatment  as  skin-burns,  and  unless  the  damage 
has  been  ver}'  severe  the  hairs  will  reappear.  Drop- 
ping  out  of  the  hairs   of    the   eyebrows    and   other 


172  THE  EYE. 

defects  may  be  treated  in  the  same  manner  as  hair- 
defects  elsewhere. 

The  eyelids  are  composed  of  thin,  loose  skin, 
elastic  tissue,  delicate  muscle,  and  plates  of  carti- 
lage, called  the  tarsal  cartilages,  which  give  the  lids 
shape  and  firmness.  The  upper  lid  is  the  larger  and 
is  movable,  while  the  lower  lid  is  almost  stationary. 
There  is  no  fat  in  the  eyelids,  and  if  this  were  not 
the  case,  in  extreme  obesity  they  would  become  closed 
by  their  weight.  However,  the  loose  tissue  of  the 
lids  affords  an  ideal  field  for  swelling,  and  after  blows 
or  in  inflamuiatory  conditions,  such  as  erysipelas,  we 
find  the  lids  sometimes  so  swollen  as  to  be  entirely 
closed. 

The  ordinary  "  black  eye"  is  simply  extravasation 
of  blood  into  the  loose  tissues  of  the  lid,  from  which 
it  is  some  little  time  in  being  absorbed.  In  recent 
injury  or  disease  of  the  lids,  cold  in  the  form  of  iced 
compresses  is  indicated  to  prevent  further  exudation, 
while  in  the  later  stages  hot  compresses  are  necessary 
to  promote  absorption  of  the  exudation  or  hemorrhage 
which  has  already  taken  place.  There  is  no  virtue 
in  a  poultice  beyond  the  continued  heat,  and  local 
medicinal  measures  are  of  little  value.  For  cos- 
metic purposes  a  bruised  lid  may  be  painted  flesh 
color. 

The  delicate  construction  of  the  eyelid  enables  the 
physician  to  judge  well  of  the  general  circulation 
from  its  appearance.  A  dark  hue  of  the  skin  of  the 
lids,  the  so-called  "rings  around  the  eyes,"  is  indica- 
tive of  a  sluggish  circulation  or  of  changes  in  the 
composition  of  the  blood.  Puffiness  or  swelling  of 
the  lids,  popularly  known  as  "bags  under  the  eyes," 


THE    KYIUJDS.  173 

is  often  an  early  sign  of  disease  of  the  heart  or 
kidney. 

The  lids  arc  lined  with  a  very  smooth  membrane, 
called  the  conjunctiva,  which  will  be  spoken  of  later. 
They  are  maintained  in  close  apposition  to  tiie 
eyeball  by  atmospheric  pressure.  They  move  freely 
and  without  friction  on  account  of  the  smoothness  of 
their  inner  surfaces  and  the  outer  surface  of  the  eye- 
ball, and  the  lubrication  by  the  tears  and  the  mucus 
secreted  by  the  conjunctiva.  On  the  edges  of  the 
lids,  near  the  roots  of  the  lashes,  are  the  small  Mei- 
bomian glands,  which  secrete  an  oily  substance 
greasing  the  lid-borders  and  helping  to  prevent  the 
overflow  of  tears. 

An  important  function  of  the  lids  is  to  distribute 
the  tears  over  the  front  of  the  eyeball,  and  by  inces- 
sant winking  to  free  the  front  of  the  eye  from  dust 
and  keep  it  moist.  The  winking  also  acts  as  a 
hydraulic  pump  in  discharging  the  excess  of  tears 
through  the  tear-duct  into  the  nose,  besides  affording 
frequent  intervals  of  rest  for  the  retina.  When  the 
eyelids  are  paralyzed  or  when  on  account  of  protru- 
sion of  the  eyeball  they  cannot  be  closed,  the  front  of 
the  eyeball,  or  cornea,  quickly  loses  its  lustre  and 
transparency,  and  unless  this  is  speedily  remedied 
blindness  will  ensue. 

The  protective  function  of  the  eyelids  is  very  evi- 
dent, and  is  so  automatic  that  the  lids  close  reflexly 
at  the  approach  of  a  foreign  body  or  a  threatened 
blow. 

The  opening  between  the  lids  is  called  the  com- 
missure, and  on  the  width  and  breadth  of  this  de- 
pends the  size  of  the  eye.     When  one  speaks  of  a 


174  THE   EYE. 

large  eye  or  a  small  eye,  reference  is  made  to  the  size 
of  the  palpebral  commissure  and  not  to  the  size  of 
the  eyeball.  There  is  no  noticeable  difference  in  the 
actual  size  of  healthy  eyeballs,  except,  of  course,  as 
belongs  to  the  different  ages,  the  child  having  a 
smaller  eyeball  than  the  adult.  However,  in  some 
persons  the  size  of  the  pupil  gives  to  the  eye  an  addi- 
tional element  of  size.  The  racial  characteristics  are 
transmitted  in  the  size  and  shape  of  the  commissure, 
as  is  shown  in  the  almond  eye  of  the  Mongolian. 
The  shape  of  the  commissure  has  a  marked  influence 
upon  the  expression  and  upon  the  personal  beauty. 
Actresses  avail  themselves  of  dextrous  pencilling  to 
prolong  the  shadow  of  the  commissure  and  produce 
impression  of  large  eyes.  A  villainous  expression  is 
made  by  pencilling  the  outer  angles  of  the  commis- 
sure upward.  A  drooping  and  partially  closed  lid 
gives  the  impression  of  languor,  and  it  is  also  used 
by  artists  to  portray  fatigue  and  voluptuous  passion. 
In  the  final  stages  of  wasting  diseases  the  half-closed 
eye  is  a  sign  of  impending  physical  dissolution. 

The  eyelashes,  or  cilia,  are  given  off  from  the  lid- 
border,  and  differ  from  the  hair  elsewhere  by  their 
finer  texture  and  in  being  thicker  in  the  middle  than 
at  the  ends.  They  are  arranged  in  two  curves,  those 
of  the  upper  lid  having  their  convexity  downward 
while  those  of  the  lower  lid  have  their  convexity 
upward.  Thus  when  the  lids  are  partially  closed,  the 
eyelashes  interlace,  forming  a  screen  against  wind, 
dust,  or  excessive  light,  while  still  allowing  the  en- 
trance of  light  and  vision.  They  are  supplied  with 
sensitive  nerves  at  their  roots  which  serve  to  warn 
against  the  approach  of  small  bodies  when  in   the 


THE  EYELASHES,    OR   CHJA.  1/5 

dark,  or  when  the  vision  is  intently  employed 
elsewhere.  The  lashes  are  constantly  being  renewed 
but  the  falling  out  should  not  be  noticeable. 

In  certain  inflammatory  conditions  of  the  lid- 
border,  known  as  blepharitis,  the  eyelashes  may  so 
fall  out  as  to  become  very  sparse.  If  the  inflamma- 
tion is  allowed  to  go  untreated,  there  is  often  formed  a 
permanent  "blear  eye;"  the  new  lashes  come  in 
stijETand  are  often  misdirected,  turning  in  toward  the 
eyeball  instead  of  outward.  These  wandering  lashes 
are  popularly  known  as  "  wild  hairs,"  and  cause 
great  discomfort  by  constantly  rubbing  against  the 
sensitive  cornea.  Such  errant  cilia  must  be  con- 
stantly pulled  out,  or  their  bulbs  must  be  destroyed 
by  electricity,  and  in  some  cases  even  a  plastic  oper- 
ation on  the  lids  is  necessary  for  relief. 

Inflammation  of  the  lid-edges  with  destruction  and 
distortion  of  the  lashes  is  a  most  unsightly  facial 
blemish,  and  if  not  properly  treated  will  grow  pro- 
gressively worse.  In  a  great  number  of  cases  it  is  one 
of  the  many  results  of  ocular  congestion  from  un- 
corrected eye-strain,  and  will  only  be  relieved  by  the 
wearing  of  the  proper  glasses.  Salves  and  ointments 
may  alleviate,  but  will  never  cure  such  cases.  In  other 
instances  blepharitis  is  a  local  expression  of  a  general 
disease  showing  elsewhere  in  the  skin,  and  will  only 
yield  to  general  medicinal  and  dietetic  treatment  in 
the  hands  of  a  competent  ph3'sician.  Kn  exceptional 
cause  is  the  presence  of  tiny  insects,  nits,  pediculosis 
(lice),  or  scabies  (itch),  at  the  roots  of  the  lashes.  In 
some  cases  the  vitality  of  the  lashes  is  lowered  in 
common  with  that  of  the  hair  elsewdiere.  In  such 
cases  a  stimulatine  or  irritant  treatment  is  indicated. 


176 


THE  EYE. 


The  lacrimal  or  tear  apparatus  (Fig.  37)  consists 
of  a  lacrimal  gland  which  secretes  the  tears.  It  is 
situated  at  the  upper  and  outer  angle  of  the  orbit, 
and  is  connected  to  the  conjunctival  cul-de-sac  be- 
tween the  eyelids  and  the  eyeball  by  eight  to  twelve 


Lacrimal 
gland' 

Tarsal 
cartilage 


Canaliculus 
Fig.    37. — Diagram  of  the  lacrimal  apparatus. 


small  ducts  which  open  by  a  series  of  pores  about  ^-^ 
of  an  inch  apart,  at  a  little  beyond  the  border  of  the 
upper  lid.  The  tears  are  discharged  from  the  gland 
into  the  conjunctival  sac  and  flow  across  the  front  of 
the  eyeball  toward  the  inner  corner  of  the  eyelids, 
where  they  are  received  in  a  small  opening  in  both 
upper  and  lower  lid-borders,  called  the  punctum. 
From  here  they  flow  through  two  minute  canals, 
called  the  lacrimal  canalicull,  to  the  lacrimal  sac, 
or  "tear-bag,"  lodged  in  a  groove  in  the  lacrimal 
bone  below  the  inner  angle  of  the  lid-commissure,  or 
internal  canthus.  When  distended,  this  sac  forms  a 
protrusion  at  the  inner  angle  of  the  lids  and  may  be 
compressed  through  the  lower  lid,  expelling  its  con- 
tents through  the  punctum  into  the  conjunctival  cul- 
de-sac  or  into  the  nose.      From  the  lacrimal  sac  the 


CONSTANT  EXCESSIVE  LACRIMATION.  1 77 

tears  are  directed  through  a  bony  canal,  •)^  inch 
long-,   called  the  nasal  duct,  into  the  nose. 

The  forces  at  work  in  the  passages  of  the  tears 
from  the  gland  to  the  nose  are  capillary  attraction,  as 
furnished  in  the  canals,  gravity  causing  them  to  fall 
over  the  conjunctiva  and  through  the  canals,  and 
muscular  movement  of  the  lids  in  winking.  In  the 
act  of  winking  the  tear-sac  is  expanded  by  traction 
of  the  muscles,  and  the  tears  are  sucked  into  it;  then 
passive  contraction  of  the  tense  elastic  sac  expels 
the  tears  on  through  the  nasal  duct  into  the  nose. 

Ordinarily  there  is  such  a  perfect  balance  between 
the  secretion  and  excretion  of  tears  that  by  no  sub- 
jective sign  are  we  conscious  of  them.  When,  how- 
ever, from  emotion  or  by  irritation  from  the  wind, 
dust,  pungent  vapors,  or  intense  light  there  is  an  ex- 
cessive secretion  of  the  tears  they  may  overflow  the 
lids  and  roll  down  the  face  as  well  as  be  felt  in  the 
nose.  In  crying  or  on  a  windy  day  there  is  usually 
an  accompanying  "sniffling"  or  "blowing  of  the 
nose, ' '  due  to  an  increased  amount  of  tears  draining 
into  the  nasal  chambers.  Infants  do  not  shed  tears 
until  after  the  third  month. 

Constant  excessive  lacrimation  with  overflow  on 
the  cheek,  or  epiphora,  commonly  called  "tearing" 
or  "  watering  of  the  eyes,"  may  be  due  to:  i.  Living 
in  vapors  or  dust  or  chemicals,  as  millers,  metal- 
grinders,  excessive  smokers,  etc. ;  2.  Inflammation 
of  the  lid-membrane  (conjunctivitis);  3.  Eye-strain, 
either  from  excessive  reading  or  working  in  bad  light 
or  from  defective  eyes.  If  a  careful  inquiry  into  the 
patient's  habits  and  an  examination  of  his  inner  lid- 
surfaces  reveal  no  cause  for  the  tearing,  examination 
12 


178  THE  EYE. 

of  the  eyes  under  complete  cycloplegia  is  advisable. 
When  the  tear-sac  is  distended  and  inflamed  (dacryo- 
cystitis) very  serious  disturbance  may  result  if  the 
cause  is  not  properly  treated  by  a  physician. 

Ttie  conjunctiva  is  the  thin,  transparent  mucous 
membrane  that  lines  the  front  of  the  eyeball  and  is 
reflected  to  the  inner  surfaces  of  the  eyelids,  forming, 
when  the  lids  are  shut,  a  closed  sac.  Except  over  the 
cornea,  the  conjunctiva  is  quite  vascular,  and  on  ac- 
count of  its  many  small  blood-vessels  it  is  quite  likely 
to  become  congested  from  irritation,  injury,  or  dis- 
ease, causing  what  is  popularly  known  as  "  pink  eye  " 
or  "red  eye."  As  an  example,  note  the  quickness  of 
the  eye  to  become  red  from  the  irritation  of  excessive 
tear-supply  in  weeping  or  following  the  irritating 
vapor  of  tobacco-smoke,  or  lodgement  of  a  small 
foreign  body. 

The  conjunctiva  is  continuous  with  the  mucous 
membrane  of  the  nose  and  mouth.  Hence  in  in- 
flammation of  the  nasal  mucous  membrane,  as  in  an 
ordinary  "cold  in  the  head"  or  in  influenza,  the 
conjunctiva  is  quite  likely  to  become  much  congested. 
In  fact,  in  such  cases  people  speak  of  ' '  catching  cold 
in  the  eyes."  Again,  in  inflammation  of  the  alimen- 
tary tract  in  chronic  alcoholism  or  after  a  debauch  it 
is  common  to  see  the  "  blood-shot  eye." 

True  inflammation  of  the  conjunctiva  is  called 
conjunctivitis.  Ordinary  catarrhal  conjunctivitis,  or 
"red  eyes,"  is  most  commonly  due  to  eye-strain, 
and  until  excessive  eye-work  is  forbidden  and  the 
proper  correcting  lenses  are  ordered  the  conjunctivitis 
will  continue  to  occur.  Students  who  use  their 
eyes   excessively  and   often   by  poor  light,  firemen, 


"GRANlfLAK   I.IDSr  1 79 

piiddlers,  and  others  who  arc  exposed  to  great  glares 
or  dazzling  lights  are  subject  to  conjunctivitis. 
Other  causes  are  chronic  nasal  catarrh,  diseases  of 
the  tear-apparatus,  working  in  irritating  vapors,  ex- 
cessive smoking,  particularly  in  a  sitting  position  in- 
doors, where  clouds  of  smoke  are  constantly  wreathed 
about  the  head  and  face.  The  roughened  membrane 
gives  rise  to  a  continual  sense  of  foreign  body  in 
the  eye  which  causes  the  patient  to  rub  and  further 
irritate  the  membrane.  The  burning  and  smarting 
are  sometimes  intolerable.  A  pleasant  eye-lotion  in 
such  cases  is  a  2  per  cent,  solution  of  boric  acid  in 
water. 

Purulent  conjunctivitis  is  fortunately  a  rare  dis- 
ease, as  it  speedily  may  become  most  fatal  to  the  eye, 
causing  the  clear  cornea  to  ulcerate,  often  destroying 
not  only  the  sight,  but  also  the  whole  eye.  It  is  puru- 
lent conjunctivitis  of  new-born  infants  that  is  such  a 
prolific  cause  of  blindness.  Immediately  upon  the 
appearance  of  red  eyes  in  the  first  few  days  of  life  a 
physician  should  be  summoned.  A  few  hours'  delay 
with  home  treatment  may  mean  blindness  for  the 
child.  The  greatest  care  should  be  taken  to  prevent 
contagion  in  any  household  in  which  there  is  a  puru- 
lent conjunctivitis.  All  towels,  cloths,  compresses, 
etc.,  used  on  the  patient  should  be  destroyed,  and  the 
soap  and  basins  used  should  be  kept  separate,  and  if 
only  one  eye  is  infected  every  precaution  should  be 
taken  to  shield  its  fellow.  One  patient  with  purulent 
conjunctivitis  has  infected  a  whole  family,  several  of 
the  cases  resulting  most  disastroush*. 

"  Granular  lids  "  is  a  name  often  given  to  ordinary 
chronic  conjunctivitis  by  the  laity.     True  granular 


l8o  THE   EYE. 

lids,  or  trachoma,  is  a  much  more  serious  affection 
and  is  particularly  obstinate.  The  inner  conjunc- 
tival surface  of  the  lids  becomes  roughened  and  by 
constantly  irritating  the  cornea  impairs  its  transpar- 
ency. The  inflammation  also  gives  rise  to  distressing 
distortion  of  the  lid-borders  by  the  formation  of  con- 
tracting scar-tissue,  which  causes  misdirection  of  the 
eyelashes,  so  that  they  turn  in  against  the  globe,  a 
condition  known  as  entropion.  This  disease  is  most 
common  among  the  poorer  classes,  and  particularly 
where  many  are  huddled  together  in  one  dwelling 
and  where  dwellings  are  closely  built.  It  is  often  al- 
most epidemic  in  barracks  and  charitable  institutions. 
When  once  an  inmate  of  an  almshouse,  asylum, 
or  school  has  been  attacked  by  a  severe  case  of  con- 
junctivitis of  any  kind,  he  should  be  immediately 
reported  to  the  physician  and  forbidden  to  use  the 
public  towels,  soap,  or  wash-troughs,  and  should  as 
far  as  possible  be  isolated  from  his  fellows  until  his 
disease  is  cured.  In  the  same  way  applicants  for  ad- 
mission to  large  institutions  or  conscripts  should 
have  their  eyes  scrupulously  examined,  even  to  ever- 
sion  of  the  upper  lid,  to  be  sure  that  there  is  no 
trachomatous  disease  present. 

There  is  nearly  always  affection  of  the  conjunctiva 
in  measles — in  fact,  the  "  measly  eye  "  is  well  known. 
Certain  other  infectious  diseases,  such  as  scarlet  fever, 
small-pox,  and  diphtheria,  may  seriously  affect  the 
conjunctiva  and  cornea,  even  causing  blindness.  The 
nurse  and  medical  attendant  in  their  anxiety  to  pre- 
serve life  should  not  neglect  the  necessary  precautions 
to  protect  the  eyes  from  serious  invasion. 

Subconjunctival    hemorrlnages   are    usually   the 


SUBCONJUNCTIVAL    HEMORRHAGES.  l8l 

result  of  a  blow  or  other  injury,  but  tliey  sometimes 
occur  spontaneously,  and  often  in  the  niglit  while 
asleep.  While  not  always  true,  it  may  be  said  that 
this  is  indicative  of  brittle  or  degenerated  blood- 
vessels, and  that  unless  precautions  are  taken  a  cere- 
bral apoplexy  may  follow.  Hemorrhages  of  the 
conjuctiva  sometimes  occur  in  violent  coughing  or 
in  straining  at  stool. 

Many  persons  suffering  more  or  less  continuously 
from  inflamed  eyes  are  in  the  habit  of  treating  them- 
selves and  paying  no  regard  to  the  cause  of  the  dis- 
ease. They  resort  to  the  quack  ' '  eye- waters  ' '  or 
"  eye-drops,"  many  of  which  contain  powerful  drugs, 
such  as  cocain  and  atropin,  the  constant  use  of  which 
only  further  augments  the  trouble. 

A  question  often  asked  is,  whether  hot  or  cold 
water  is  better  for  the  eyes,  and  even  persons  with 
healthy  eyes  continually  bathe  their  eyes  "to  make 
them  strong."  In  perfectly  healthy  eyes  it  is  always 
unnecessary  to  use  continuously  any  eye-wash  or  to 
open  the  eyes  under  water.  The  conjunctiva  of  man 
differs  from  that  of  a  fish,  and  any  prolonged  expos- 
ure to  water  will  surely  cause  irritation.  In  acute 
inflammations  the  application  of  cold  water  is  sooth- 
ing and  retards  inflammation;  after  the  inflammation 
is  well  under  way,  continued  applications  of  very  hot 
water  may  help  in  constricting  the  blood-vessels,  re- 
ducing swelling,  and  relieving  pain.  However,  in 
cases  of  chronic  conjunctivitis  the  patient  is  usually 
suffering  from  some  unknown  exciting  cause  contin- 
ually operative,  most  likely  eye-strain;  and  instead 
of  atteinpting  to  treat  himself  or  indifferently  allow- 
ing the  disease  to  progress,  he  should  consult  an  ocu- 


l82  THE  EYE. 

list  as  to  the  advisability  of  wearing  glasses  or  other 
treatment.  If  the  habit  of  using  eye-washes  is  firmly 
established,  a  very  pleasant  and  harmless  lotion  is 
made  by  dissolving  40  grains  of  boric  acid  in  4 
ounces  of  distilled  water,  rose-water,  or  camphor- 
water,   and  afterward  filtering. 

The  proper  way  to  use  an  eye-lotion  is  as  fol- 
lows: The  patient  should  throw  the  head  far  back 
or  recline  in  a  chair  or  on  a  couch  and  look  upward. 
The  lower  lid  is  gently  pulled  downward,  and  with  a 
clean  glass  pipette  or  eye-dropper  several  drops  of 
the  solution  are  placed  quickly  but  gently  in  the  corner 
of  the  eye.  The  lids  should  not  be  violently  closed, 
as  in  such  case  the  liquid  is  all  squeezed  out  on  the 
cheek;  but  the  eyeballs  should  be  slowly  rotated, 
dijBfusing  the  fluid  over  all  parts  of  the  conjunctival 
cul-de-sac.  The  lotion  should  be  allowed  to  dry  in 
the  eye,  and  should  not  be  wiped  out  with  a  handker- 
chief. The  pipette  should  be  cleansed  before  being 
used  again.  It  is  well  to  keep  the  lotion  in  a  bottle 
with  a  sufficiently  small  neck  to  allow  the  glass 
pipette  to  act  as  a  stopper  in  place  of  the  ordinary 
cork.     The  use  of  eye-cups  is  not  recommended. 

Growths  of  the  Conjunctiva. — Often  fatty  deposits 
in  the  conjunctiva  cause  needless  alarm.  A  Pinguecula 
is  a  small,  yellowish  growth  on  the  conjunctiva  over 
the  eyeball,  which,  although  often  progressively  in- 
creasing, never  causes  discomfort  or  needs  treatment. 
A  pterygium  is  a  fleshy  growth  on  the  conjunctiva 
with  the  base  toward  either  canthus  and  apex  toward 
the  pupil.  This  growth  is  common  in  old  people, 
and  especially  in  those  who  have  been  exposed  for 
years  in  outdoor  occupations,  as,  for  instance,  in  sail- 


rilE    COKNF.A.  183 

ors.  It  is  not  maliji^naiit,  and  if  it  enlarges  so  nmch 
as  to  interfere  with  tlie  motion  of  the  eyeball  or  to 
obscnre  vision  it  may  lie  easily  removed. 

The  cornea  may  be  called  the  window  of  the  eye. 
It  is  a  transparent  smooth  tnnic  enclosing  the  anterior 
fifth  of  the  eyeball.  It  is  circnlar,  and  by  the  way  it 
is  fitted  into  the  sclera  it  resembles  a  watch-crystal. 
It  is  without  blood-vessels,  bnt  is  supplied  with  an 
abundance  of  nerves,  making  it  very  sensitive.  Dis- 
ease of  the  cornea  is  very  disastrous  to  vision,  especi- 
ally when  the  central  portion  over  the  pupil  is  affected, 
as  it  is  quite  likely  to  leave  white  scars  which  greatly 
interfere  with  vision.  Unless  formed  in  early  child- 
hood, these  opacities  are  not  likely  to  clear  up.  Dis- 
eases of  the  cornea  are  also  very  painful  on  account 
of  the  abundant  nerve-supply,  and  the  pain  caused 
by  exposure  to  light  is  great. 

Corneal  disease  occurs  particularly  in  persons  who 
are  run  down  in  health,  and  in  sickly  or  congenitally 
diseased  children,  who  also  show  signs  of  ill-health 
elsewhere,  such  as  bad  teeth,  nasal  catarrh,  etc.  In 
such  cases  a  rigorous  tonic  and  dietetic  treatment  is 
as  necessary  as  local  measures. 

Fortunately,  the  cornea  is  very  tough  and  resistant, 
as  it  is  the  part  of  the  eye  most  exposed.  It  is  washed 
with  tears  continually  to  clear  it  of  small  particles  of 
dust  and  keep  it  polished  and  transparent.  It  is  fre- 
quently the  seat  of  injury,  and  affords  a  common  loca- 
tion for  lodgement  of  foreign  bodies. 

It  is  not  uncommon,  among  persons  wdio  have 
not  made  a  careful  study  of  the  eye,  for  white  scars 
on  the  cornea  resulting  from  injury  or  disease  to  be 
mistaken  for  cataract.     Old  corneal  opacity  cannot 


1 84  THE  EYE. 

be  removed,  and  is  a  prominent  cause  of  incurable 
blindness;  in  fact,  in  former  years  the  greater  num- 
ber of  inmates  of  blind  asylums  owed  their  trouble  to 
opacity  of  the  cornea  following  either  "sore  eyes  of 
the  new-born"  (ophthalmia  neonatorum)  or  small- 
pox. 

Arcus  senilis  is  a  circular  opacity  at  the  periphery 
of  the  cornea,  seen  generally  in  aged  persons.  It  is 
sometimes  mistaken  for  beginning  cataract.  It  is  the 
result  of  a  senile,  degenerative  process,  and  is  not 
dangerous  to  the  eyeball,  and  never  interferes  with 
vision,  as  it  is  so  far  removed  from  the  center  of  the 
cornea. 

The  sclera  is  the  external  tunic  of  four-fifths  of  the 
eyeball.  It  is  continuous  with  the  cornea  in  front. 
It  is  an  opaque,  tough  fibrous  membrane,  and  forms 
the  chief  support  of  the  eyeball.  By  reason  of  the 
white  appearance  of  its  anterior  surface  it  is  com- 
monly called  the  "white  of  the  eye"  (Fig.  38). 


upper  lid-border 


Iris  ixnth  corneal 

reflex  anterior 

Sclera 


Lower  lid-border 

Fig.  38. — The  anterior  surface  of  the  eyeball. 

Tine  iris  (Fig.  38)  is  a  circular  contractile  mem- 
brane made  up  of  elastic  and  muscular  tissue,  blood- 
vessels, and  nerves  suspended  from  the  edges  of  the 
cornea  in  the  front  of  the  eye  like  a  curtain.     The 


'riJE  jRis.  185 

iris  gives  the  color  to  the  eye  ;  and  when  we  say  that 
an  eye  is  blue  or  brown  we  mean  that  this  is  the  color 
of  the  iris.  This  color  of  the  iris  is  derived  in  part 
from  a  purplish  pigment,  and  is  due  in  part  to  certain 
optical  phenomena  of  reflection  of  light  from  uneven 
surfaces.  The  iris  is  freely  movable,  and  according 
to  whether  it  dilates  or  contracts  we  have  an  alteration 
in  the  size  of  its  central  aperture,  called  the  pupil. 

The  color  of  the  iris  at  birth  is  blue,  which,  how- 
ever, changes  in  the  first  few  weeks  to  the  permanent 
color.  In  albinos  there  is  an  absence  of  pigment  in 
the  iris  as  well  as  in  the  hair  and  skin,  allowing  the 
red  reflex  from  the  blood-vessels  in  the  choroid  to 
shine  through,  giving  the  eyes  a  pinkish  hue.  As  a 
particular  function  of  the  pigment  of  the  iris  is  to 
prevent  transmission  of  light-rays  through  its  sub- 
stance to  prevent  dazzling,  in  albinos  there  is  great 
distress  on  exposure  to  light.  There  is  a  popular 
superstition  that  certain  colored  eyes  are  stronger 
than  others.  There  is  nothing  in  this  belief  other 
than  that  a  dark-colored  iris  is  perhaps  better  fitted 
to  protect  the  retina  from  intense  sun-glare,  and  hence 
is  found  more  among  the  tropical  nations,  while  light- 
colored  eyes  are  more  general  among  the  northern 
races.  In  our  climate  bluish  or  grayish  eyes  may 
be  as  serviceable  as  those  of  darker  color. 

The  chief  function  of  the  iris  is  by  contracting  and 
dilating  to  regulate  the  amount  of  light  admitted  to 
the  interior  of  the  eye.  This  has  a  protective  as  well 
as  an  optical  purpose.  In  the  presence  of  a  strong 
light  the  pupil  quickly  contracts,  shutting  out  exces- 
sive light  ;  while  in  subdued  light  or  semi-darkness  it 
dilates,  allowing  more  light  to  enter.     When  looking 


1 86  THE  EYE. 

at  a  distance  or  when  looking  languidly  into  space 
the  pupils  dilate.  Artists  take  advantage  of  this  fact, 
and  in  portraying  pensiveness  or  reverie  paint  large 
pupils  in  the  eyes.  In  using  the  eye  at  close  range 
the  accommodation  is  brought  into  play  in  a  manner 
described  later  (page  208),  and  the  pupil  is  also  con- 
tracted, allowing  more  distinct  vision.  The  optical 
principle  herein  may  be  easily  demonstrated  by  any- 
one with  defective  vision  who  will  look  through  a 
pin-hole  in  a  disk  or  card.  They  will  see  almost  as 
distinctly  as  with  their  glasses,  although,  of  course, 
they  do  not  have  as  great  a  field  of  vision. 

Any  interference  with  the  movements  of  the  pupil 
indicates  either  inflammatory  synechise  or  serious 
brain-  or  nerve-disease.  However,  the  pupil  may  be- 
come dilated  and  inactive  after  the  use  of  certain  drugs 
called  mydriatics.  Among  these  are  belladonna  and 
its  alkaloid  atropin,  cocain,  and  homatropin.  Miotics 
are  drugs  which  contract  the  pupil.  Among  these  are 
calabar  bean  and  its  alkaloid  eserin,  pilocarpin,  and 
opium.  One  of  the  prominent  symptoms  of  profound 
opium-poisoning  is  pin-point  contraction  of  the  pupil, 
which  dilates  just  before  death. 

The  Size  of  the  Pupils. — In  health  the  pupils  are 
of  equal  size  and  react  to  light  synchronously,  but 
there  is  great  difference  in  the  normal  size  in  diflferent 
persons.  Late  in  life  the  pupil  grows  gradually 
smaller,  in  a  measure  compensating  for  the  ocular 
defects  incident  to  age.  Marked  inequality  in  the 
size  of  the  pupil  is  generally,  though  not  always,  in- 
dicative of  serious  brain-  or  nerve-disease. 

I^arge  pupils  are  generally  and  properly  considered 
a  sign  of  beauty,  and  it  is  sometimes  the  practice 


THE    OPHTIIALMOSCOrE. 


187 


among  actresses,  singers,  and  other  women  who  ap- 
pear in  public  to  produce  an  artificial  dilatation  by  the 
use  of  a  weak  mydriatic  solution.  A  large  pupil  in- 
dicates a  particularly  active  sympathetic  system,  and 
persons  with  large  pupils  are  more  subject  to  asthe- 
nopia from  astigmatism  or  other  refractive  defects. 
It  is  in  such  people  that  insignificant  correcting  lenses 
produce  the  most  marked  beneficial  efifects.  vStrong 
emotions  and  passions  cause  dilatation  of  the  pupil. 
The  typical  picture  of  fright  is  a  dilated  pupil  with 
widely  parted  eyelids. 

Ordinarily  the  pupil  appears  black.  Rays  of  light 
entering  the  eye  through  a  pupil  are  reflected  back  in 
the  same  direction  in  which  they  enter  ;  and  as  our 


Fig.  39. — Ophthalmoscope. 


own  eye  is  not  the  source  of  light  or  in  line  with  the 
source  of  light  the  pupil  appears  black.  When,  how^- 
ever,  the  observer's  eye  is  artificially  made  the  source 
of  lioht,  and  if  he  looks  in  the  same  direction  as  that 


THE  EYE. 


in  wliicli  the  luminous  rays  enter  the  observed  eye, 
as,  for  instance,  through  the  central  sight-hole  of  a 
reflecting  mirror  (Fig.  39),  illumination  renders  the 
interior  of  the  eye  visible.  This  is  the  fundamental 
principle  of  the  ophthalmoscope;  and  the  simplest 
form  of  ophthalmoscope  is  a  mirror  in  the  center  of 


Fig.  40. — The  normal   eye-ground  as  seen   with   the   ophthalmoscope:    n, 
optic  nerve-head;  m,  macula;  a,  retinal  artery;  v,  retinal  vein. 

which  is  scraped  an  opening  in  the  silvered  back, 
through  which  the  observer  looks  at  the  eye  under 
observation.  By  directing  the  reflection  of  a  lamp-  or 
gas-flame  into  the  observed  eye  and  looking  through 
the  sight-hole  in  the  mirror  there  is  seen  the  red  re- 
flex of  the  choroid  in  the  pupillary  space,  and  by  com- 
ing closer  to  the  pupil  there  may  be  seen  the  blood- 


iRrns.  189 

vessels  of  the  retina  and  the  shining  white  head  of  the 
optic  nerve  (Fig.  40).  This  is  better  accomplished  by 
darkening  the  room  and  placing  the  source  of  light 
back  of  the  subject's  head,  as  the  pupil  then  becomes 
dilated  and  the  contrast  is  greater. 

By  subdued  light  the  pupils  of  certain  animals  pre- 
sent a  bright  glare.  This  is  particularly  noticeable 
in  the  domestic  cat,  and  is  due  to  reflection  from  a 
modified  choroid,  called  the  tapetum  lucidum,  a  bril- 
liant greenish  reflecting  membrane  between  the  retina 
and  sclera. 

Inflammation  of  the  iris  is  called  iritis,  and  is  a 
very  painful  and  dangerous  disease,  sometimes  caus- 
ing blindness.  At  the  onset  it  resembles  conjuncti- 
vitis, and  is  often  attributed  to  ' '  catching  cold  in  the 
eye."  The  patient  should  not  attempt  to  treat  it  by 
home  remedies  or  common  eye-lotions,  until  the  dis- 
ease has  been  allowed  to  progress  so  far  as  to  bind  the 
iris  down  to  the  lens-capsule.  In  such  cases  a  few 
drops  of  atropin  solution  applied  under  the  guidance 
of  a  skilled  oculist  would  render  this  accident  impos- 
sible. 

The  ciliary  body  is  situated  at  the  junction  of  the 
iris  and  choroid,  and  is  quite  susceptible  to  diseases 
affecting  either  membrane.  It  is  composed  of  sixty 
or  seventy  folds  formed  by  reduplications  of  the 
choroid  at  its  anterior  margin,  called  the  ciliary  proc- 
esses, and  a  grayish  transparent  band  of  muscular 
tissue  about  one-eighth  inch  broad,  called  the  ciliary 
muscle.  This  consists  of  radiating  and  circular 
fibers,  the  former  arising  from  the  junction  of  the 
cornea  and  sclera,  passing  backward  to  the  choroid 
opposite  the  ciliary  processes  ;  the  latter  are  internal, 


IQO 


THE   EYE. 


and  pursue  a  circular  course  around  the  insertion  of 
the  iris.  This  little  muscle  is  an  important  factor  in 
accommodation  and  eye-strain,  and  is  spoken  of  at 
length  later  (see  page  210). 

The  choroid  is  the  vascular  and  pigmentary  tunic 
of  the  eyeball  investing  the  posterior  five-sixths  of 
the  globe,  extending  as  far  forward  as  the  cornea  and 
developing  ciliary  processes  from  its  inner  surface 
anteriorly.  It  lies  between  the  sclera  externally  and 
the  retina  internally.  Its  function  is  to  supply  blood 
to  the  interior  of  the  eye  and  to  absorb  superfluous 
liffht.  Inflammation  of  the  choroid  is  called  cho- 
roiditis,  and  is  generally  the  result  of  systemic  disease, 
particularly  of  the  type  accompanied  by  disease  of  the 
blood-vessels.  Other  causes  are  injury,  infection, 
high  myopia,  retinitis,  and  iridocyclitis.  Disease  of 
the  choroid  is  particularly  disastrous  to  vision  on 
account  of  involvement  of  the  contiguous  mem- 
brane, the  retina,  and  the  continuous  structures,  the 
ciliary  body  and  iris. 

The  retina  is  the  innermost  of  the  three  coats  of 
the  eyeball,  and  is  the  chief  peripheral  portion  of 
the  visual  apparatus.  It  is  made  up  of  the  percipient 
end-organs  and  expansion  of  the  fibers  of  the  optic 
nerve  in  the  eyeball.  It  is  composed  of  three  main 
layers:  the  inner,  of  fibers  and  nerve-cells;  the  granu- 
lar middle  layer;  and  an  internal  layer,  composed  of 
rods  and  cones  and  pigment.  The  rods  and  cones 
are  the  essential  sight-elements.  The  light  entering 
the  eyeball  through  the  pupil  impinging  on  the  cones 
is  received  and  transmitted  through  the  other  layers 
to  the  optic  nerve,  and  thence  on  to  the  visual  centers 


THE  RETINA.  I9I 

in  the  brain.     The  retina  is  freely  supplied  with  blood- 
vessels. 

The  most  sensitive  part  of  the  retina  is  the  macula 
lutea,  or  central  spot,  which  covers  an  area  of  about 
one-fiftieth  of  an  inch  in  diameter,  to  the  temporal  side 
of  the  entrance  of  the  optic  nerve.  In  the  very  center 
of  this  part  of  the  retina  is  the  fovea  centralis,  in  which 
all  the  layers  are  missing  but  the  essential  cones.  So 
important  is  this  minute  portion  of  the  membrane 
that  if  it  is  encroached  upon  and  destroyed  by  dis- 
ease, useful  vision  is  lost,  although  the  peripheral 
part  of  the  retina  may  be  intact.  In  such  a  case, 
if  the  patient  looked  directly  at  an  object  he  could 
not  see  it,  although  he  would  have  an  indistinct  view 
of  the  objects  at  either  side  of  it.  It  can  be  readily 
understood  how  helpless  in  reading  or  working  at 
close  range  such  a  person  would  be.  On  the  other 
hand,  considerable  areas  of  the  surrounding  retina 
may  be  destroyed  and  yet  useful  vision  be  pre- 
served, provided  the  macular  region  is  intact,  the 
extent  of  side  vision  only  being  limited.  However, 
defects  in  the  retina  may  cause  blind  spots  in  the 
field  of  vision,  called  scotomas.  There  is  a  natural 
blind  spot  at  the  entrance  of  the  optic  nerve.  This 
may  be  demonstrated  by  experiments  wath  the  cross 
and  circle  described  on  page  193. 

The  retina  has  often  been  compared  to  the  sensitive 
plate  of  a  camera,  and  from  this  comparison  have 
arisen  such  absurd  statements  as  the  finding  of  a, 
photograph  of  a  murderer  in  his  victim's  eye.  The 
retinal  images  are  not  permanent,  as  witnessed  by  the 
numerous  and  rapid  succession  in  which  the}'  change. 
However,  even  this  rapidity  has  a  limit.     If  we  take 


192  THE  EYE. 

a  firebrand  and  twirl  it  around  rapidly  in  front  of 
the  eyes,  it  is  impossible  for  the  eye  to  perceive  the 
images  of  the  fire  in  each  position  of  its  revolution; 
and  instead  of  several  pictures  of  the  burning  brand 
we  see  only  a  circle  of  fire.  That  retinal  images 
have  some  permanency  of  duration,  however,  is  proved 
by  looking  intently  at  a  luminous  object  for  some 
time  and  then  turning  the  gaze  against  a  black  wall 
or  ceiling  for  a  moment,  when  there  will  be  seen  the 
image  of  the  object  still  before  the  eyes  against  the 
new  surface.  No  one  has  ever  discovered  a  retinal 
image,  and  to  see  it  in  the  eye  of  a  human  being  as 
described  in  sensational  newspaper  reports  the  ob- 
server would  have  to  use  an  ophthalmoscope,  other- 
wise these  retinal  images  would  be  invisible.  To  be 
seen  with  the  naked  eye,  the  image  must  be  located 
on  the  cornea  or  iris,  and  for  an  image  to  be  placed 
here  would  require  the  interposition  and  accurate  ad- 
justment of  a  convex  lens  between  the  face  of  the 
assailant  and  the  eye  of  the  victim — a  most  preposter- 
ous supposition. 

The  optic  nerve  connects  the  retina  with  the 
brain.  Its  sole  function  is  to  carry  sensations  of 
light.  It  does  not  convey  the  sensation  of  pain. 
Disease  or  injury  to  the  retina  and  optic  nerve  may 
occur  to  such  an  extent  as  to  cause  blindness  with- 
out the  victim  ever  suffering  the  slightest  local  pain. 
When  suddenly  shocked,  the  optic  nerve,  instead  of 
giving  a  sensation  of  pain,  gives  rise  to  indefinite 
sensations  of  light,  such  as  are  commonly  known  as 
"seeing  flashes"  or  "stars."  Unlike  the  retina, 
the  optic  nerve  cannot  receive  impressions  of  light 
any    more  than   a   telegraph   wire   can   receive   and 


THE    OPTIC  NERVE.  1 93 

interpret  a  message.  They  are  botli  only  means  of 
conveyance  of  impressions.  In  fact,  at  the  point  in 
the  eye-gronnd  where  the  optic  nerve  enters  there  is 
a  normal  blind  spot  which,  projected  into  the  field 
of  vision,  constitntes  the  well-known  "  Mariotte's 
blind  spot."  This  may  be  readily  demonstrated  by 
directing  the  right  eye  accurately  to  the  cross  in  Fig. 
41.     Closing  the  left  eye  and  withdrawing  the  page 


Fig.  41. — Diagram  to  demonstrate  the  "  blind  spot." 

to  about  ten  inches  from  the  eye  the  circle  will 
entirely  disappear,  for  at  this  point  the  image  of 
the  circle  falls  directly  on  the  unresponsive  optic 
nerve-head. 

Serious  disease  of  the  optic  nerve,  by  interrupt- 
ing the  means  of  communication  between  the  retina 
and  brain,  produces  blindness.  It  is  generally  the 
result  of  systemic  disease,  but  may  be  due  to  the 
excessive  use  of  alcohol,  tobacco,  or  other  noxious 
substance.  Complete  atrophy  of  the  optic  ner\^e 
is  an  incurable  disease,  and  when  total  there  is  not 
even  perception  of  light  left,  and  sometimes  contrast 
between  bright  light  and  darkness  is  lost. 

The  humors  making  up  the  bulk  of  the  eyeball 
are  called  the  aqueous  and  the  vitreous.  They  are 
both  perfectly  transparent  for  the  free  transmission  of 
light.     The  aqueous  humor  occupies  that  part  of  the 

13 


194  THE  EYE. 

eyeball  in  front  of  the  crystalline  lens  and  is  a  slightly 
alkaline  watery  fluid.  The  vitreous  humor  occupies 
the  large  part  of  the  eyeball  lying  behind  the  crystal- 
line lens  and  is  a  jelly-like  substance.  Disease  of 
the  various  membranes  of  the  eyeball  may  disturb  the 
transparency  of  the  humors,  causing  either  diffuse 
clouding  and  blindness,  or  only  single  floating  opaci- 
ties showing  as  dark  spots  before  the  eyes.  These 
are,  however,  quite  visible  to  the  physician  by  the 
ophthalmoscope,  and  must  not  be  confounded  with 
the  microscopic  opacities  known  as  muscse  volitan- 
tes  that  are  often  present  in  healthy  eyes.  These 
smaller  opacities  are  invisible  by  the  ophthalmo- 
scope, but  are  readil}^  seen  by  the  patient,  particu- 
larly if  he  is  myopic.  They  are  brought  out  much 
plainer  in  looking  against  a  light  wall,  a  white  sur- 
face, or  at  the  sky  on  a  clear  day.  In  certain  cases 
of  eye-strain  they  become  very  annoying  and  assume 
different  shapes,  such  as  strings  of  beads,  rings,  flakes, 
etc.,  floating  down  before  the  eye.  In  some  patients 
they  are  complained  of  worse  during  attacks  of  "  bil- 
iousness."  These  dark  spots  before  the  eyes  are 
variously  considered  as  intra-ocular  evidence  of 
waste-tissue  accumulation,  the  results  of  sexual  dis- 
turbances, etc.  Although  they  become  very  terri- 
fying to  the  patient  at  times,  as  a  rule  they  speedily 
diminish  or  become  ignored  when  the  defective  eyes 
are  corrected  by  the  proper  glasses  and  there  is  rest 
from  excessive  ocular  labor. 

The  crystalline  lens  is  a  biconvex  transparent  body 
about  one-third  of  an  inch  long  and  less  than  half  as 
thick,  enclosed  in  an  equally  transparent,  homogene- 
ous capsule.     It  rests  against  the  vitreous,  and  is  par- 


CATARACT.  1 95 

tially  covered  in  front  by  the  iris.  It  is  held  in  place 
by  the  suspensory  ligament.  The  substance  of  the 
lens  is  arranged  in  concentric  layers  composed  of 
minute  fibrils  which  dovetail  into  each  other.  This 
arrangement  gives  the  lens  somewhat  the  power  of  a 
watch-spring,  which,  when  allowed  to  relax  by  the 
contraction  of  the  ciliary  muscle,  becomes  more  con- 
vex anteriorly.  This  phenomenon  is  spoken  of  later 
in  describing  accommodation  (page  208). 

Cataract  is  opacity  of  the  crystalline  lens  or  its 
capsule,  and  may  be  partial  or  complete.  It  is  not 
an  incurable  disease,  and  does  not  always  cause  blind- 
ness. It  is  not  a  "growth  on  the  eye,"  and  it  must 
not  be  confounded  with  corneal  opacities.  In  cataract 
the  cornea  is  transparent  and  the  iris  and  pupil  are 
readily  seen  ;  but  the  pupil,  instead  of  being  black,  is 
grayish-white,  and  the  vision  may  be  reduced  to  the 
mere  recognition  of  light  and  darkness.  Many  people 
have  unripe  cataract  and  are  never  cognizant  of  the 
fact,  because  that  part  of  the  crystalline  lens  in  front  of 
the  pupil  never  becomes  opaque.  Only  a  few  opaque 
radii  may  be  seen  when  the  pupil  is  dilated  by  a 
mydriatic.  Too  much  stress  cannot  be  laid  upon  this 
fact,  as  often  the  oculist,  after  failing  to  improve  the 
vision  with  glasses,  is  compelled  to  explain  to  the 
patient  the  reason  of  his  failure,  and  if  the  patient  is 
nervous  he  imagines  he  has  a  horrible  growth  akin  to 
cancer  elsewhere,  and  will  become  permanently  blind. 
With  prescription  and  frequent  changing  of  the  proper 
glasses,  together  with  the  best  hygienic  precautions 
and  careful  systemic  treatment,  incipient  cataract  may 
not  only  fail  to  grow  worse,  but  actually  clear  up  to  a 
slight  degree.     Again,  so  long  as  vision  remains  good 


196  THE  EYE. 

in  one  eye  there  is  no  necessity  of  operating  on  its 
cataractous  fellow. 

The  causes  of  simple  senile  cataract  are  not 
exactly  known.  Old  age  predisposes  to  it,  but 
whether  by  weakened  nutrition,  general  arterial 
sclerosis,  or  undue  strain  on  the  accommodation  in 
presbyopia,  we  are  unable  to  say  definitely  ;  but  cer- 
tain it  is  that  cataract  is  seen  less  frequently  where 
the  care  of  the  eyes  is  properly  understood.  It  is 
rare  among  persons  of  the  better  classes  who  have 
been  careful  of  their  eyes  and  who  have  used  lenses 
ordered  by  competent  oculists  at  frequent  intervals, 
instead  of  neglecting  their  eyes  or  using  lenses 
selected  carelessly  in  an  optician's  shop  or  a  jewelry 
store. 

It  is  true  that  the  use  of  proper  glasses,  the  treat- 
ment of  associate  local  or  constitutional  disease,  and 
the  observance  of  ocular  hygiene  may  retard  or  pre- 
vent the  maturing  of  incipient  cataract;  but  the 
treatment  of  mature  cataract  by  drugs  or  apparatus 
is  useless.  When  once  it  is  complete  there  is  no  cure 
but  a  siirgical  operation.  There  are  frequently  adver- 
tised numerous  remedies  and  treatments  "without  the 
knife,"  which  are  mostly  solutions  of  some  mydri- 
atic, which  by  dilating  the  pupils  allow  the  en- 
trance of  more  light  and  hence  improve  vision  tem- 
porarily. These  are  all  made  with  the  idea  of  im- 
posing on  the  credulity  of  the  victims  of  cataract, 
who  are  foolishly  ready  to  try  any  treatment  that  may 
be  substituted  for  the  "dreaded  operation,"  which, 
fortunately,  in  the  hands  of  a  skilful  surgeon  is  almost 
always  successful.  The  prescribed  operation  consists 
in  cutting  an  opening  in  the  rim  of  the  cornea,  open- 


GLAUCOMA.  197 

ing  the  capsule  of  the  lens,  and  removing  tlic  opaque 
lens  from  its  bed  in  the  pupillary  space,  f  )f  course, 
in  the  place  of  the  lens  removed,  an  artificial  lens  must 
be  worn  in  front  of  the  eye  in  spectacles  ;  and  as  great 
refractive  pov^^er  as  well  as  the  power  of  accommoda- 
tion has  gone  with  the  natural  lens,  a  separate  pair  of 
glasses,  or  bifocal  lenses,  must  be  worn  for  near  work. 

Sometimes  in  the  onset  of  cataract  the  crystalline 
lens  swells  before  it  begins  to  become  opaque,  and 
by  this  change  in  refraction  the  aged  person  is  en- 
abled to  read  for  the  first  time  in  many  years  without 
glasses.  This  is  the  so-called  "  second  sight." 
However,  if  the  distance  vision  is  taken  it  will  very 
likely  be  found  quite  defective,  and  generally  the 
typical  opacity  of  cataract  progresses,  and  if  the 
patient  lives  long  enough  vision  is  almost  totally 
lost,  and  operation  is  necessitated. 

Glaucoma  is  a  disease  of  the  eye  in  which  the 
characteristic  symptoms  are  steadily  increased  hard- 
ness of  the  globe,  with  pressure  and  cupping  of  the 
optic  nerve,  and  pressing  forward  of  the  iris  and 
dilatation  of  the  pupil.  It  is  due  either  to  exces- 
sive secretion  or  blocking  of  the  excretory  channels 
of  the  eyeball.  It  is  a  very  fatal  disease  to  vision 
and  is  very  resistant  to  treatment.  It  is  most  com- 
mon in  females  and  appears  generally  after  middle 
life.  The  local  medicinal  treatment  is  application  of 
miotic  drugs  to  contract  the  pupil  and  reduce  the 
tension.  Atropin  and  other  mydriatics,  by  dilating 
the  pupil,  aggravate  the  condition,  and  may  hasten 
an  incipient  attack.  Persons  with  glaucoma  are  liable 
to  inflammation  of  the  conjunctiva,  and  are  frequently 
seekino;   to  chanee  their  elasses.     The  careless  and 


198  THE  EYE. 

indiscriminate  use  of  popular  eye-lotions  or  eye-drops 
containing  some  mydriatic  in  glaucomatous  inflam- 
mation, or  the  administration  by  an  optician  or  other 
layman  of  a  mydriatic  preliminary  to  testing  for 
glasses  in  cases  of  glaucoma,  has  caused  the  loss  of 
many  eyes  (see  page  220). 

Injuries  to  the  Eyes. — We  have  already  mentioned 
the  numerous  ways  in  which  this  delicate  and  im- 
portant organ  is  protected  by  Nature.  The  bony 
orbit  and  the  cushion  of  fat  enclose  the  eye  behind; 
the  orbital  margin,  eyebrows,  eyelids,  eyelashes,  and 
nose  protect  it  in  front  and  laterally;  while  the  tough 
sclera  and  cornea  form  coverings  not  easily  pene- 
trated. When  a  blow  or  a  foreign  body  is  directed 
toward  the  eye,  automatically  by  reflex  action  the 
lids  close  and  the  eyeballs  roll  up,  presenting  the 
tough  and  opaque  sclera  instead  of  the  important 
transparent  cornea  to  arrest  the  force  of  violence. 
In  fact,  in  penetrating  wounds  of  the  eye  directly 
through  the  lids  the  injury  is  generally  on  the  lower 
sclera,  the  cornea  having  been  too  quickly  rotated 
upward  and  out  of  the  line  of  contact  to  be  injured. 

Non-penetrating  Foreign  Bodies. — The  most 
common  form  of  injury  is  the  entrance  of  small 
particles  of  dust,  cinder,  steel-filings,  etc.,  into  the 
conjunctival  sac  or  into  the  substance  of  the  cornea. 
Often  the  tears  will  wash  such  particles  as  are  not 
embedded  toward  the  inner  canthus,  where  they  cause 
no  symptoms  and  can  be  seen  by  the  patient  and 
wiped  out.  However,  the  foreign  body  may  lodge  and 
be  hidden  from  view  in  the  upper  or  lower  sulcus  of 
the  lid  or  be  embedded  in  the  cornea,  and  can  only  be 
seen  with  difficulty  by  the  unaided  eye.    It  will  quickly 


NON-PJCNKTRA'J'ING   FOREIGN  BODIES. 


'99 


cause  intolerable  nibbing  and  grating,  which  neces- 
sitate frequent  winking  or  complete  closure  of  the 
lid  before  there  is  comfort.  The  eye  soon  becomes 
congested  and  the  conjunctiva  inflamed.  In  such 
cases  the  surface  of  the  bulbar  conjunctiva  and  cornea 
should  first  be  inspected  in  a  bright  light  or  by 
oblique  illumination  with  a  magnifying  lens.  The 
lower  sulcus  of  the  conjunctiva  is  then  brought  into 


Fig.  42. — Preliminary  step  in  everting  the  upper  eyelid. 


view  by  simple  tension  on  the  lower  lid  downward 
with  one  finger.  If  the  oflfending  particle  is  not  seen, 
the  upper  lid  should  be  everted  (Figs.  42,  43).  This 
may  easily  be  eflfected  without  the  aid  of  a  probe  or 
other  instrument,  and  everyone  should  learn  the  ma- 
nipulation, as  there  is  often  opportunity  in  travelling 
to  relieve  some  unfortunate  sufferer  by  this  simple 
procedure.     The  patient  is  told  to  look  down,  the 


200 


THE  EYE. 


edge  of  the  lid  and  the  lashes  are  seized  with  the 
thumb  and  forefinger  of  the  right  hand,  and  the 
lid  is  drawn  at  first  forward  and  then  downward 
away  from  the  globe;  then  upward  over  the  point 
of  the  thumb  or  forefinger  of  the  left  hand,  which 
is  held  stationary  on  the  lid  and  acts  as  a  fulcrum. 
The  foreign  body  should  be  removed  with  a  hand- 
kerchief or  wisp  of  cotton;  but  if  it  is  embedded  it 
may  be  necessary  for  a  competent  physician  to  release 
it  with  the  point  of  a  sterilized  needle,  or  spud,  or  a 


Cinder 


Fig.  43. — The  upper  eyelid  everted. 

magnet  under  cocain-anesthesia.  Embedded  particles 
are  most  common  in  marble-cutters,  grinders,  engi- 
neers, firemen,  and  the  like.  In  every  shop  there 
is  some  workman  who  is  skilled  in  removing  for- 
eign bodies,  and  who  does  not  in  his  ignorance  of 
the  serious  consequences  hesitate  to  pick  at  the  em- 
bedded particle  with  a  rusty  knife-blade  or  needle, 
without  previously  washing  his  soiled  hands.  De- 
structive corneal  ulcers  following  such  manipulations 
are  not  uncommonly  seen  in  large  eye-hospitals. 
Penetrating    Foreign    Bodies. — The   dangers    of 


BURNS   OF  THE   EYE.  20I 

embedded  foreign  bodies  are  not  the  most  serious  in 
these  exjiosed  trades.  The  foreign  body  often  com- 
pletely penetrates  the  eyeball,  destroying  vision  of 
not  only  the  injured  eye,  but  sometimes  that  of  its  fel- 
low by  sympathetic  inflammation  following  delayed 
or  improper  treatment.  There  is  no  more  serious 
injury  to  the  eyeball  than  penetration  by  a  foreign 
body,  and  often  vision  is  not  only  lost,  but  also  the 
eyeball  must  be  taken  out  to  avoid  sympathetic 
inflammation.  An  eye  with  a  foreign  body  in  it  is 
always  dangerous,  as  it  is  liable  to  break  out  at  any 
time  into  active  inflammation.  In  spite  of  these 
dangers  the  employes  in  such  hazardous  occupations 
refuse  to  wear  protective  glasses.  There  should  be  a 
rule  in  every  establishment  where  the  nature  of  the 
work  causes  many  eye-injuries  that  no  employe  shall 
be  allowed  to  work  without  protective  glasses,  and 
casualty  companies  should  refuse  to  take  risks  on 
such  employes  unless  this  rule  is  enforced. 

Penetrating  wounds  of  the  eyeball  are  very 
serious,  especially  when  through  the  ciliary  region, 
and  often  necessitate  enucleation.  If,  however,  the 
lens  alone  is  the  seat  of  injury,  a  traumatic  cataract 
may  be  the  only  result,  and  this  may  absorb  under 
appropriate  treatment  without  more  serious  result 
than  follows  an  ordinary  cataract-operation. 

Burns  of  the  eye  are  not  uncommon.  Usually 
the  conjunctiva  and  cornea  are  involved,  and  immo- 
bility of  the  globe  or  blindness  may  follow  on  account 
of  contraction  of  the  scarred  membrane  and  growing 
of  the  raw  surface  of  the  lid  to  the  ball,  with  perhaps 
opacity  of  the  cornea.  Quicklime  is  particularly 
dangerous  to  the  eye.     The  most  important   treat- 


202  THE   EYE. 

ment  in  such  cases  is  to  remove  quickly,  forcibly, 
and  thoroughly  all  the  irritating  substance.  This 
should  be  followed  by  the  instillation  of  a  drop  of 
concentrated  sugar  solution.  Afterward,  a  teaspoou- 
ful  of  sweet  oil  may  be  instilled,  and  is  very  soothing. 
In  cases  of  acid-burns,  bathing  the  eye  with  milk  is 
advised.  Immediately  after  the  first  emergency 
treatment  the  case  should  be  placed  in  the  hands  of  a 
physician. 

AMETROPIA  AND  EYE=STRAIN. 

The  eyeball  has  very  aptly  been  compared  to 
a  camera.  Rays  of  light  from  a  luminous  object 
enter  the  pupil.  The  mobile  iris  acts  like  the 
diaphragm  of  a  camera,  shutting  off  rays  which  are 
too  divergent  to  be  properly  refracted,  while  the 
remaining  rays  are  focussed  accurately  on  the  sensi- 
tive surface  of  the  retina  by  the  crystalline  lens  and 
other  refractive  media  of  the  eye  (Fig.  44).  How- 
ever, here  the  analogy  ceases,  for  instead  of  the 
retina  retaining  a  permanent  impression  like  the 
sensitive  plate  of  the  camera,  it  is  simply  stimulated 
by  the  impingement  of  the  light-rays,  and  the 
impressions  caused  thereby  are  transmitted  'to  the 
centers  of  sight  in  the  brain  by  means  of  the  optic 
nerve,  optic  tracts,  etc. ,  in  a  manner  somewhat  analo- 
gous to  telegraphy. 

It  must  be  remembered  that  the  eyeball  does  not 
see.  It  is  only  a  sensitive  end-organ  which  receives 
and  transmits  impressions  to  the  higher  centers  of 
sight.     The  act  of  vision  is  performed  in  the  brain. 

For  the  performance  of  perfect  vision  the  following 
conditions  are  necessary:  (i)  The  media  of  the  eye 


AMETROPIA   AND   KYK-STRAIN. 


203 


must  be  perfectly  transparent;  (2)  rays  of  lij^ht  enter- 
ing the  eyeball  must  be  transmitted  through  the 
pupil  and  foeussed  exactly  on  the  retina;  (3)  the 
retina,  optic  nerve,  and  its  continuations  must  be 
perfect;  (4)  the  visual  centers  in  the  brain  must  be 
intact.  In  other  words,  the  receiving,  transmitting, 
and  interpreting  apparatus  must  all  be  perfect.  A 
disturbance  of  any  component  of  the  visual  system 


Fig.  44. — A   camera  obscura  and  the  eyeball  compared  :  A  B,  object ; 
d,  diaphragm  (iris) ;  /,  lens  ;  r,  sensitive  plate  (retina)  ;   a  b,  image  of  A  B; 


c,  cornea. 


may  cause  defective  vision,  and  even  blindness.  In 
cases  of  cataract,  the  retina,  optic  nerve,  and  brain 
may  be  healthy,  but  the  opaque  lens  behind  the  pupil 
prevents  light  from  reaching  the  retina.  In  atrophy 
of  the  optic  nerve  or  disease  of  the  retina,  the  media 
of  the  eyeball  may  be  perfectly  transparent  and 
properly  direct  rays  of  light  to  the  retina,  and  the 
brain  may  be  healthy,  but  blindness  ensues  because 


204  THE  EYE. 

the  impressions  either  are  not  received  or  are  not 
transmitted.  In  disease  of  the  visual  centers  of  the 
brain  the  whole  eyeball  may  be  normal  and  the  optic 
nerve  perfect,  but  blindness  results  from  the  inability 
of  the  brain  to  interpret  the  impressions  transmitted 
to  it. 

In  this  discussion  it  is  with  the  focussing  power 
of  the  eyes  that  we  are  chiefly  concerned.  This 
property  of  bending  nearly  parallel  rays  of  light  from 
distance  and  divergent  rays  from  close  range  so  that 
they  meet  exactly  on  the  sensitive  retina  is  called 
refraction. 

Emmetropia  is  the  refractive  condition  in  which 
rays  of  light  entering  the  eyeball  from  a  distance  are 
focussed  exactly  on  the  retina.  The  emmetropic  is 
the  normal  eye  (Fig.  45). 


•    Fig.  45. — The  course  of  light-rays  in  an  emmetropic  eye. 

Ametropia  is  the  refractive  condition  in  which 
distant  rays  of  light  entering  the  eyeball  are  not 
accurately  focussed  on  the  retina.  There  are  three 
varieties  of  ametropia:  hyperopia  (far-sightedness), 
myopia  (near-sightedness),  and  astigmatism. 

Hyperopia  (far-sightedness). — In  this  condition 
the  eyeball  is  too  short,  and  rays  of  light  from  a 
distance  are  focussed  behind  the  retina  (Fig.  46,  f\ 
Instead  of  being  distinct  as  in  the  emmetropic  eye, 
the  image  is  blurred,  and  the  eye  is  adjusted  for  dis- 


ASTIGMATISM. 


205 


tance  rather  than  close  ran^c.  Hyperopia  is  cor- 
rected by  a  convex  lens  which  converges  the  rays 
of  light,  bringing  them  sooner  to  a  focus. 


Fig.  46. — Diagram  showing  a  hyperopic  eye  focussing  parallel  rays  of 
light  at/",  behind  the  retina,  and  /,  the  convex  lens,  which,  converging  the 
rays  toward  r,  causes  them  to  be  focussed  exactly  on  the  retina,  thus  cor- 
recting the  hyperopia.  * 

Myopia  (near-sightedness). — In  this  condition, 
by  reason  of  greater  length  of  the  eyeball  or  increased 
refractive  changes  in  the  media,  rays  of  light  from  a 
distance  are  focussed  in  front  of  the  retina,  producing 
an  indistinct  image  (Fig.  47,  f).     The  myopic  eye  is 


Fig.  47. — Diagram  showing  a  myopic  eye  focussing  parallel  rays  at  f 
in  the  vitreous,  and  requiring  the  concave  lens  /,  vi^hich  will  cause  them  to 
diverge  as  from  r,  in  order  that  they  shall  be  focussed  exactly  on  the  retina. 

adjusted  for  close  range  rather  than  for  distance. 
Myopia  is  corrected  b}^  a  concave  lens,  which  diverges 
rays  of  light,  prolonging  the  focal  distance. 

Astigmatism   is  a  condition  in    which    the   focus 
may  be  either  in  front  of  or  behind  the  retina,  or 


2o6 


THE   EYE. 


both,  but  by  different  amounts  for  two  or  more 
meridians  of  the  eye.  In  simple  hyperopia  or  myo- 
pia all  the  meridians  of  the  eye  are  equally  defective. 
In  simple  astigmatism  one  principal  meridian  is  nor- 
mal while  the  other  is  faulty.  In  compound  astig- 
matism both  meridians  are  hyperopic  or  myopic,  but 
unequal  in  degree.  In  mixed  astigmatism  one  merid- 
ian is  hyperopic  while  the  other  is  myopic.  Astig- 
matism does  not  depend  on  the  length  of  the  eyeball, 
but  upon  the  curvature  of  the  cornea,  and  rarely  that 
of  the  lens. 

In    Fig.  48,    a  case  of  hyperopic   (far-sighted)  as- 
tigmatism,  the  meridian  vv  is  normal,  focussing  at 


£---A' 


Fig.  48. — -The  course  of  rays  in  simple  hyperopic  astigmatism  :  h  h  pass 
through  the  hyperopic  meridian  (after Thorington). 

v\    exactly  on  the   retina.     The   meridian  at  right 
angles,  /^/^,  is  hyperopic,  focussing  at  /^',  behind  the 


Fig.  49. — Correction  of  the  astigmatism  by  a  convex  cylinder. 

retina.  In  this  condition  a  point  of  light  is  focussed 
as  a  blurred  line.  Astigmatism  is  corrected  by  a  cyl- 
indric  lens,  which  has  a  plane  surface  in  one  axis  and 
a  curved  surface  in  the  axis  at  right  angles  to  it.     This 


ACCOMMODA  TION. 


207 


form  of  lens  is  really  a  seginciit  of  a  cylinder  of  solid 
glass.  The  axis  of  the  cylinder  is  placed  at  right 
angles  to  the  faulty  meridian  (Fig.  48,  hii). 

In  simple  astigmatism,  on  looking  at  an  astig- 
matic chart  (Fig.  50)  with  each  eye  separately, 
certain   of    the    lines     in     the     defective     meridian 


Fig.  50. — Astigmatic  chart. 

seem  very  much  blurred,  while  those  at  exact  right 
angles  appear  clear  and  black.  This  furnishes  a  test 
for  astigmatism,  as  to  an  emmetropic,  or  normal,  eye 
the  lines  appear  of  equal  distinctness  and  black- 
ness. Astigmatism  is  very  common,  and  although 
we  speak  of  hyperopic  and  myopic  eyes  separately  for 
purposes  of  optical  explanation,  it  may  be  stated  that 
nearly  all  eyes  in  highly  civilized  communities,  irre- 
spective of  their  length,  are  in  some  degree  astig- 
matic. 

Accommodation. — Until  now  we  have  spoken  of 
the  eye  as  an  organ  at  rest,  focussed  for  nearly  par- 


208 


THE  EYE. 


allel  rays  from  a  distance.  Close  to  the  eye  the 
light-rays  have  an  appreciable  divergence;  yet  we 
know  that  notwithstanding  the  inadaptability  of  the 
eye  for  focussing  such  rays  it  is  quite  possible  up 
to  middle  age  to  receive  distinct  retinal  images 
of  objects  within  a  few  inches  of  the  eye.  This 
change  of  focus  is  effected  by  an  act  called 
accommodation,  which  is  accomplished  by  an  in- 
crease in  the  convexity  of  the  crystalline  lens  behind 
the  pupil.  This  lens  is  held  in  place  by  its  suspensory 
ligament,  the  tension  of  which  is  controlled  by  the 


Corneal  epithelium 

Bowman' s  me^nbrane 

Cornea  proper 

Descemet' s  membrane 

Corneal  endotheliutn 

Sphincter  of  the  iris 

Canal  of  Schlemrn 

Ciliary  muscle 


Ciliary  processes 


Zonula  of  Zinn 

Fig.  51. — Comparative  diagrarr  showing  the  change  in  the  shape  of  the 
crystalline  lens  during  accommodation.  The  right  side  shows  the  lens  at 
rest. 


ciliary  muscle.  During  accommodation  the  ciliary 
muscle  contracts,  relaxing  the  suspensory  ligament, 
and  the  lens  bulges  forward  by  its  inherent  elasticity 
and  the  refractive  power  is  increased  (Fig.  51).  By 
means  of  accommodation  all  reading,  writing,  sew- 
ing, and  other  near  work  is  made  possible.  The 
power  of  accommodation  is  greatest  in  early  life,  and 
gradually  diminishes  until  about  the  age  of  forty, 
when  reading  at  the  ordinary  distance  becomes  un- 
comfortable. At  about  seventy-five  years  the  accom- 
modation is  practically  lost. 


ANISOAfE  'I  'K  or  J  A .  209 

This  physiologic  failure  of  accommodation 
beyond  the  point  of  comfortable  reading  is  called 
presbyopia,  or  old-age  siglnt,  and  every  person 
over  forty-five  years  willi  normal  or  far-sighted 
eyes  should  wear  glasses  to  read  and  perform  other 
ocular  work.  Presbyopia  is  corrected  by  convex 
glasses,  which  must  be  strengthened  every  few 
years.  The  presbyopic  correction  must  be  used  in 
addition  to  any  distance-correction.  Old  persons 
cannot  wear  the  same  glasses  for  distance  and  for 
near. 

Near-sighted  persons,  although  unable  to  see  dis- 
tinctly at  a  distance,  are  enabled  by  the  increased 
refractive  power  of  their  eyeballs  to  read  without 
glasses  even  in  old  age.  Sometimes  the  distant  point 
of  a  near-sighted  eye  is  as  close  to  the  eye  as  the 
ordinary  reading-distance  (twelve  to  fourteen  inches), 
and  in  such  cases  reading  is  effected  without  accom- 
modation at  the  far  point  of  the  eye.  Whenever  a 
person  is  heard  boasting  of  the  ability  of  himself  or 
some  relative  to  read  in  old  age  without  glasses,  it 
may  be  taken  for  granted  that,  instead  of  the  vision 
being  extraordinarily  preserved,  the  eyes  are  near- 
sighted, and  perhaps  all  through  life,  distance-vision 
without  glasses  has  been  imperfect,  although  reading 
and  near  work  were  distinct. 

Anisometropia,  or  marked  difference  in  the 
refraction  of  the  two  eyes  in  the  same  person,  is 
not  unusual;  in  fact,  one  eye  may  be  far-sighted 
and  the  other  near-sighted,  and  yet  the  patient, 
being  able  to  read  at  a  distance  with  the  far-sighted 
eye  and  at  close  range  with  the  near-sighted  one, 
may  go  through  life  never  realizing  that  the  eyes  are 

14 


210  THE  EYE. 

different  or  defective.  Strange  to  say,  persons  are 
sometimes  seen  who  have  been  almost  blind  in  one 
eye  from  childhood,  and  who  have  become  conscious 
of  this  fact  only  when  told  by  an  oculist  in  later  life. 
However,  inequality  of  the  refractive  power  of  the 
two  eyes  is  very  likely  to  cause  severe  eye-stra'in 
with  its  accompanying  symptoms,  which  necessitates 
a  visit  to  the  oculist. 

The  Mechanism  of  Eye-strain. — Comparatively 
few  eyes  are  perfect.  Most  persons  are  slightly 
far-sighted  or  astigmatic,  but  many  such  persons 
have  apparently  perfect  vision  despite  their  defective 
eyes.  Near-sighted  persons,  however,  always  show 
defective  vision,  although  near  vision  may  be  perfect 
and  close  work  may  be  done  comfortably  without 
accommodative  strain;  in  fact,  acquired  near-sighted- 
ness is  by  some  considered  as  an  attempt  of  Nature 
to  produce  an  eye  adapted  to  the  increasing  ocular 
labor  of  modern  civilization. 

The  question  naturally  follows.  How  can  far- 
sighted  or  astigmatic  eyes  secure  for  their  owner  per- 
fect vision?  The  answer  is.  Simply  by  the  use  of 
accommodation.  By  constant  strain  on  the  ciliary 
muscle  the  crystalline  lens  is  so  increased  in  curva- 
ture as  to  counterbalance  exactly  the  optical  defects 
of  these  eyes,  and  so  long  as  the  accommodation  holds 
{i.-  e.  well  into  middle  life)  the  patient  has  no  trouble 
in  distance  vision.  If  he  follows  an  outdoor  occupa- 
tion, and  has  little  use  for  his  eyes  at  near  work,  and 
his  health  keeps  good,  there  is  no  consciousness  of 
eye-strain.  But  if  the  employment  is  indoors  in  a 
clerical  occupation  or  in  reading  and  in  studying,  or 
if  the  general  health  fails,  there  may  develop  from 


THE  LOCAL    SYMLTOMS   OF  EYLi-STKAIN.        211 

the  incessant  loss  of  nervous  vitality  in  eye-strain  a 
chain  of  symptoms  collectively  known  as  astheno- 
pia. 

The  multiformity  of  the  effects  of  eye-strain  can 
only  be  properly  realized  when  we  understand  how 
vital  the  function  of  vision  is  to  every  act,  emotion, 
or  thought.  The  visual  centers  are  in  the  closest 
connection  with  the  other  brain-centers,  and  the 
slightest  disturbance  of  the  visual  mechanism,  par- 
ticularly if  the  eyes  are  used  excessively  at  close 
range,  produces  sympathetic  irritation  not  only  in  the 
eyes,  but  in  the  entire  motor,  sensory,  and  psychic 
systems.  Hapj^ily  the  manifold  effects  of  eye-strain, 
so  long  ignored,  are  being  better  appreciated  every 
day,  and  cases  of  chronic  inflammation  of  the  eyes 
and  persistent  headaches  are  quickly  sent  for  exami- 
nation of  the  refraction  of  the  eyes  instead  of  being 
dismissed  with  a  time-worn  formula  for  medicine. 

The  Local  Symptoms  of  Eye-strain. — There  may 
be  a  continual  sense  of  discomfort  in  the  eyes,  which 
organ  may  even  become  very  painful  if  used  for 
near  work.  After  a  few  moments  of  reading  the  type 
blurs  and  the  letters  run  together,  and  there  may  be 
a  difficulty  in  following  the  lines.  There  may  be 
twitching  of  the  eyelids,  and  in  extreme  cases  there 
ma}^  be  great  difficulty  in  keeping  the  eyes  open  in 
continued  reading  on  account  of  drowsiness.  The  eyes 
may  smart,  itch,  or  burn,  and  continually  "water;" 
or  they  may  appear  red  and  congested  both  on  the 
edges  of  the  lids  and  in  the  conjunctival  sac.  There 
may  be  great  sensitiveness  to  light,  causing  the  mis- 
guided patient  to  w^ear  colored  glasses  instead  of  the 
correcting  transparent  lenses. 


212  THE   EYE. 

The  General  or. Reflex  Symptoms  of  Eye-strain. 

— One  of  the  commonest  reflex  asthenopia  symptoms 
is  headache,  particularly  that  accompanied  by  nausea 
("sick-headache")  and  made  worse  by  reading,  sew- 
ing, riding  in  the  cars,  riding  backward,  shopping, 
attending  the  theater,  etc.,  although  often  there 
seems  to  be  no  particular  connection  with  excessive 
use  of  the  eyes.  The  headache  is  usually  temporal 
or  frontal,  but  it  may  be  on  the  top  of  the  head  or 
at  the  base  of  the  skull  (occipital).  The  headache 
may  be  of  the  neuralgic  type,  and  may  be  limited  to 
one  side,  and  then  not  always  on  the  side  of  the  more 
defective  eye. 

In  some  cases  the  reflex  disturbances  are  quite 
remote  from  the  eyes,  and  escape  connection  with 
eye-strain.  Obstinate  constipation  and  indigestion 
are  occasional  manifestations  of  eye-strain.  Ver- 
tigo, general  nervousness,  nervous  prostration,  in- 
somnia, and  even  chorea  and  epilepsy  are  some  of 
the  influences  of  asthenopia  on  the  nervous  system. 
In  fact,  the  general  health  may  be  so  impaired  by 
the  continual  nervous  drain  of  eye-strain  that  the 
most  serious  systemic  debility  may  result.  Unless 
the  patient  has  been  under  the  care  of  a  skilful 
physician,  who  recognizes  the  influence  of  eye-strain, 
he  may  be  medicated,  massaged,  dieted,  and  given 
many  other  forms  of  treatment  before  the  services  of 
an  oculist  are  sought. 

The  liability  to  overlook  eye-strain  as  a  reflex  cause 
in  systemic  troubles  is  in  no  small  degree  due  to  the 
fact  that  often  when  the  reflexes  are  most  prominent 
there  is  little  or  no  local  disturbance  to  direct  the 
attention  to  the  eye,  and  the  same  is  true  of  the  con- 


THE   EYE-S'J'RAIN   OE  A/ VOTES.  213 

trary.  It  may  be  iiientioiied  here  that  often  patients 
with  prominent  eye-symptoms  may  persistently  seek 
relief  from  local  treatment  when  the  canse  is  not 
ocnlar.  For  instance,  patients  are  sometimes  given 
glasses  by  unscrupulous  opticians  for  conjunctivitis 
which  may  be  of  purely  nasal  origin.  Again,  there 
is  pain  deep  in  the  orbit,  associated  with  a  dull 
headache,  particularly  distressing  on  arising  in 
the  morning,  in  some  varieties  of  uterine  disease. 
The  orbital  pain'  and  brow-ache  of  malarial  fever 
may  be  mistaken  for  an  asthenopic  reflex.  How- 
ever, the  history  of  chills  and  fever  will  prevent  a 
physician  from  making  a  false  diagnosis.  In  the 
early  stages  of  locomotor  ataxia  the  eye-symptoms 
may  be  carelessly  dismissed  with  a  prescription  for 
glasses,  allowing  the  disease  to  progress  unrecognized. 
Such  cases  are  unanswerable  arguments  for  the  neces- 
sity of  medical  supervision  in  the  diagnosis  and 
treatment  of  eye-strain. 

The  Eye-strain  of  Myopes. — We  have  spoken 
heretofore  of  the  asthenopia  due  to  hyperopia  and 
astigmatism  which  may  be  unrecognized  on  account 
of  preservation  of  perfect  vision.  There  is  still  to 
be  considered  myopia,  in  which  near  vision  may 
be  comfortable  although  the  distant  vision  is  faulty. 
No  amount  of  eye-strain  will  improve  the  distance 
vision,  because  the  more  a  near-sighted  person  strains 
the  ciliary  muscle  the  more  myopic  he  becomes.  It 
would  naturally  be  supposed  that  such  a  person 
would  immediately  seek  relief  from  an  oculist  on 
account  of  poor  distant  vision.  On  the  contrary, 
many  near-sighted  persons,  not  being  accustomed  to 
any  better  distant  vision,  and  being  able  to  perform 


214  THE   EYE. 

the  finest  work  without  effort,  are  likely  to  boast  of 
their  strong  eyes.  When  given  correcting-glasses  they 
may  even  discard  them,  saying,  perhaps,  that  objects 
at  a  distance  look  unusually  bright  or  clear,  but  that 
they  prefer  the  old  familiar  haze. 

Despite  all  arguments  to  the  contrary,  the  myope  is 
quite  as  much  in  need  of  glasses  as  the  hyperope  or 
the  person  with  simple  astigmatism..  On  account 
of  the  stretching  of  the  ocular  coats  the  nutrition 
of  the  structures  of  the  eye  is  disturbed  and  often 
the  membranes  are  vitiated  almost  to  a  point  of 
true  disease.  In  reading,  the  myope  is  inclined 
to  hold  his  .book  close.  In  so  doing  he  strains  his 
muscles  of  convergence,  producing  ocular  congestion 
and  compression  of  the  eyeball,  and  by  bending 
over  he  affords  a  favorable  position  for  distention 
of  the  ocular  veins.  Contrary  to  popular  impression, 
the  uncorrected  myopic  eye  may  be  considered  a 
"sick  eye,"  and  unless  restrictions  are  made  as 
to  the  amount  of  near  work  performed  or  unless 
the  proper  glasses  are  ordered,  permitting  reading 
at  a  safe  distance  from  the  eye,  serious  progress  of  the 
myopia  with  accompanying  intra-ocular  disease  may 
occur.  It  is  particularly  necessary  to  pay  the  strictest 
attention  to  school  hygiene  (see  page  233),  and  to 
correct  repeatedly  the  constantly  changing  refraction 
of  the  eyes  of  school-children  in  order  to  prevent  the 
serious  higher  grades  of  myopia.  Moderate  degrees 
of  myopia  which  have  been  properly  cared  for  may 
never  cause  the  patient  any  discomfort  other  than 
the  necessity  of  wearing  glasses  constantly.  Bven  if 
there  were  no  danger  of  the  progress  of  myopia  or 
intra-ocular     disease,    the    slight   inconvenience    of 


THE    OCULAR    MUSCLES. 


215 


wearing  glasses  is  many  times  offset  by  the  improve- 
ment in  distant  vision,  allowing  participation  in  out- 
door sports  and  in  the  pleasnres  of  Nature. 

The  Ocular  Muscles. — The  eyeball  is  moved  by 
six  muscles,  namely,  the  superior,  inferior,  internal, 
and  external  recti,  and  the  superior  and  inferior  ob- 
liques (Fig  52).     The  disorders  of  the  ocular  muscles 


Leva/or  of  'the  upper  eyelid 


Superior 

rectus' 


External  rectus- 
Inferior  rectus- 


Superior  oblique 
Internal  rectus 

Inferior  oblique 


Fig.  52. — The  external  ocular  muscles. 

are  of  sufficient  importance  to  be  mentioned  here,  par- 
ticularly as  squint,  muscular  imbalance,  and  muscular 
insufficiency  are  mostly  due  to  ametropia,  notwith- 
standing popular  beliefs  to  the  contrary;  and  they 
may  be  prevented  by  the  early  prescription  of  glasses, 
and  often  alleviated  or  entirely  cured  by  the  same 
treatment.  Paralysis  of  the  ocular  muscles  is  usu- 
ally the  result  of  serious  systemic  disease. 

When  the  visual  axes  of  the  two  eyes  meet  ex- 
actly at  the  point  of  observation,  the  ocular  mus- 
cles are  said  to  be  balanced  (Fig.  53).  This  mus- 
cular balance  is  maintained  by  the  perfect  anatomic 
conformation  of  the  muscles  and  equally  distributed 
innervation  to  them.     Anv  disturbance  of  these  fac- 


2l6  THE  EYE. 

tors  upsets  the  muscular  equilibrium.  If  the  inser- 
tion or  structure  of  a  muscle  is  faulty,  or  if  the 
innervation  is  anomalous,  muscular  imbalance,  or 
heterophoria,  is  produced.  This,  however,  does  not 
imply  that  binocular  fixation  become^  impossible. 
On  the  contrary,  the  visual  axes  may  be  rightly 
directed  by  increased  innervation,  and  single  vision 
maintained  in  ordinary  work.     In  true  strabismus 


Fig.  S3. — Diagram  showing  the  eyeballs  in  proper  position  during  conver- 
gence, the  visual  axes  exactly  meeting  at  A. 

or  squint,  or  permanent  deviation  (Fig.  54),  this  is 
not  possible,  and  diplopia  (double-vision)  is  only 
avoided  by  the  use  of  correcting  prisms  or  by  forcing 
one  eye  from  participation  in  the  visual  act.  In 
other  words,  in  true  strabismus,  perfect  binocular 
vision  is  impossible  without  optical  assistance,  while 
in  ordinary  muscular  imbalance,  or  heterophoria, 
binocular  vision  is  maintained  by  increased  inner- 
vation.    In  the  first,  the  anomaly  is  in  some  part 


'J-llE    CAUSE    OF  MUSCLE  DEVIATIONS.  21/ 

organic;  in  the  last,  exchisively  fnnctional.  Tlic 
importance  of  the  study  of  the  functional  anomal- 
ies of  the  ocular  muscles  is  manifest  when  we  realize 
that  the  extra  expenditure  of  nervous  energy  in  main- 
taining perfect  binocular  vision  causes  asthenopic  and 
reflex  symptoms  quite  as  annoying  as  those  due  to 
errors  of  refraction. 

The  cause  of  muscle-deviations  is  almost  alwavs 


Fig.  S4. — Diagram   showing  the  eyeballs  in   a   case  of  strabismus.     The 
visual  axes  meet  at  B  instead  of  at  A. 

a  refractive  error.  For  many  years  it  was  supposed 
by  some  authorities  that  the  defect  w^as  anatomic; 
that  the  muscles  concerned  were  too  short,  too  long, 
or  anomalously  inserted  or  attached;  and  that  the 
only  remedy  was  surgical  intervention  by  means  of 
section  of  the  tendon  (tenotomy)  and  advancement. 
To-day,  we  know  that  in  all  cases  of  muscular  devia- 
tion not  the  result  of  paralysis,  the  prescription  of 
the  proper  glasses  is  the  first  treatment.     In  young 


2l8  THE   EYE. 

children  the  squint  will  usually  disappear  after  the 
glasses  are  worn,  but  if  correction  of  the  ametropia 
and  properly  prescribed  exercises  do  not  restore  mus- 
cle-equilibrium after  several  months,  then  the  surgi- 
cal measures  may  be  tried. 

The  involuntary,  or  automatic,  movements  of  the 
eyes,  such  as  the  rotation  in  reading,  are  intimately 
associated  with  the  act  of  accommodation.  For 
instance,  when  a  book  or  paper  is  brought  close  to 
the  eye  there  is  an  innervation  to  the  ciliary  mus- 
cle, forcing  it  into  action,  thus  changing  the  focus 
of  the  crystalline  lens,  so  that  it  will  receive  rays 
of  light  from  the  near  object  and  place  them  exactly 
upon  the  macula  of  the  retina.  At  the  same  time 
the  two  eyes  must  converge  in  order  that  their  visual 
axes  shall  meet  exactly  at  the  near  object;  otherwise 
there  would  result  confusion  of  images,  or  diplopia. 
In  the  same  way  the  eyes  must  be  rotated  in  or  out, 
up  or  down,  with  a  definite  exactness,  according  as 
the  object  is  held  to  the  right,  left,  above  or  below 
the  vertical  and  horizontal  visual  planes,  otherwise 
the  visual  axes  would  not  meet  exactly  at  the  point 
of  observation.  Whether  congenital,  or  by  long 
habit — the  development  of  automatism — these  move- 
ments of  the  eyeball  are  intimately  associated,  likely 
controlled  by  one  center  or  contiguous  centers,  as  far 
as  participation  in  near  work  is  concerned,  and  there 
is  a  constant  relation  maintained  between  the  acts  of 
accommodation  and  ocular  movement.  This  is  par- 
ticularly so  with  convergence,  and  long  ago  the 
theory  of  squint  by  excessive  stimulation  of  the 
adduction  (convergence),  associated  with  excessive 
accommodation  in  hyperopic  eyes,  was  propounded, 


USE    OF  AIYDRIATICS.  2I9 

and  has  never  been  snccessfnlly  controverted.  The 
same  is  true  of  muscular  imbalance.  Attention  to 
the  ametropia  often  speedily  relieves  the  muscle- 
defect.  It  is  careful  refraction,  and  not  surgical 
operation,  that  prevents  and  cures  most  of  these  cases. 
If  operation  should  restore  muscle  balance,  the  un- 
corrected causative  eye-strain  is  still  operative,  and 
unless  corrected  by  glasses  there  may  be  a  recurrence 
of  the  deviation,  or  equally  serious  reflex  asthenopia 
symptoms  may  ensue. 

The  reason  that  oculists  use  mydriatics,  or 
"drops,"  as  they  are  popularly  called,  in  measur- 
ing the  refraction  of  the  eyes  is  frequently  asked 
for  by  the  laity,  and  there  is  a  popular  impression 
that  from  the  name  they  are  used  only  to  dilate 
the  pupil.  Mydriatics  are  used  in  refraction  of 
the  eye  to  produce  paralysis  of  the  ciliary  muscle; 
in  other  words,  as  cycloplegics.  With  the  accommo- 
dation active  in  far-sighted  and  astigmatic  persons,  it 
is  impossible  to  discover  the  full  defect  on  account 
of  the  continual  compensatory  strain  of  the  ciliary 
muscle.  Hence  by  using  a  substance  in  the  eyes 
such  as  belladonna  or  its  alkaloid,  atropin,  which 
paralyzes  the  ciliary  muscle  and  puts  the  eye  in  a 
state  of  rest,  the  interference  of  accommodation  is 
overcome.  A  far-sighted  or  astigmatic  person  with 
perfect  visual  acuity  when  the  ciliary  muscle  is 
active,  will  see  as  poorly  at  distance  under  a  mydri- 
atic as  an  equally  near-sighted  person,  because  of 
ciliary  paralysis  (cycloplegia);  and  as  there  is  no 
ability  to  strain  left,  the  full  amount  of  the  defect  is 
unmasked.  Without  a  mydriatic,  far-sighted  and 
astigmatic  persons  refuse  their  full  correction,  while 


220  THE   EYE. 

near-sighted  persons  are  liable  to  select  glasses  too 
strong  for  them.  When  the  accommodation  has 
failed  in  old  age  a  mydriatic  is  not  necessary,  but  it 
is  a  safe  rule  to  follow,  always  to  use  a  mydriatic  in 
first  refraction  of  persons  under  forty-five  years  of  age, 
and  often  ciliary  paralysis  is  necessary  for  accurate 
refraction  of  robust  patients  of  even  fifty  years.  Per- 
sons advertising  to  examine  the  eyes  of  children  and 
young  adults  accurately  without  the  use  of  mydriatics 
are  claiming  what  is  impossible  even  to  the  skilled 
oculist. 

The  Objections  to  Mydriatics. — When  "drops" 
are  put  in  the  eyes  the  resultant  paralysis  of  the  ciliary 
muscle  makes  close  work,  such  as  reading  and  sew- 
ing, impossible.  When  atropin  is  used  this  incon- 
venience is  continued  for  ten  days  or  two  weeks,  but, 
contrary  to  popular  opinion,  there  is  no  danger 
attending  the  ciliary  paralysis;  in  not  a  single 
case  has  it  become  permanent.  Accommodation 
returns  promptly  after  the  effect  of  the  drug  has 
passed  off,  leaving  the  eyes  better  for  the  rest  from 
near  work.  The  length  of  time  necessary  to  abstain 
from  near  work  is  now  shortened  to  from  thirty-six 
to  forty-eight  hours  by  the  use  of  a  new  mydri- 
atic called  homatropin,  which  many  oculists  use  in 
routine  practice  among  adults.  In  children,  time  is 
not  so  valuable,  and  as  complete  paralysis  of  accom- 
modation is  more  difficult  to  obtain,  the  stronger 
mydriatic,  atropin,  is  preferable. 

There  is  a  disease  of  middle  and  later  life,  called 
glaucoma,  in  which  the  use  of  a  mydriatic  may  pro- 
duce very  serious  results;  and  opticians,  jewelers,  and 
other  non-medical   "refractionists"  who  are  forbid- 


VISUAL    TESTS.  221 

den  by  law  to  use  "drops,"  have  made  a  great  card  of 
this  fact.  This  disease  is,  however,  very  rare,  and  is 
readily  recognized  by  the  trained  ocnlist,  who  always 
makes  careful  external  and  ophthalmoscopic  examina- 
tion before  prescribing  a  mydriatic  or  ordering  glasses. 
Although  there  is  no  danger  from  the  use  of  "  drops  " 
in  the  hands  of  the  skilled  physician,  their  promis- 
cuous employment  by  itinerant  opticians,  jewelers, 
peddlers,  and  the  like,  may  result  disastrously  to 
persons  with  glaucoma,  who  by  reason  of  their  fail- 
ing vision  are  particularly  likely  to  be  seeking  a 
change  of  glasses. 

VISUAL  TESTS. 

Testing  the  Acuity  of  Vision. — It  has  been  proved 
that  the  smallest  retinal  image  perceived  at  the 
macula  corresponds  to  a  visual  angle  of  5'.  Follow- 
ing this  principle,  test-types  have  been  constructed 
in  such  a  manner  that  every  letter  is  so  made  that 
when  at  its  proper  distance  it  subtends  an  angle  of  5'. 
The  letters  in  Fig.  55  subtend  an  angle  of  5'  when 


Fig.  55. — Two  of  Snellen's  test-types.    FiG.  56. — Test-type  for  the  illiterate. 

placed  about  twenty  feet  from  the  eye,  and  should  be 
read  easily  at  that  distance  if  the  eye  is  normal. 
For  illiterate  persons  and  children,  a  card  containing 
characters  such  as  in  Fig.  56  may  be  used.  The 
patient  is  asked  to  tell  which  way  the  prongs  of  the  E 
point — upward,  downward,  to  the  right,  or  to  the  left. 
The  only  article  required  in  testing  distant  vision 


222 


THE  EYE. 


is  a  series  of  test-letters  (Fig.  57)  so  arranged  that 
they  subtend  an  angle  of  5'  at  varying  distances 
from  10  to  200  feet.  The  distance  may  also  be  ex- 
pressed in  meters.  These  cards  may  be  procured 
for  a  merely  nominal  sum  at  any  optical  store. 
Figs.  55  and  56  placed  at  20  feet  distance  may 
be  used  by  the  reader  for  the  simple  purpose  of  find- 
ing out  whether  or  not  vision  is  normal. 

In  using  the  large  card  of  test- 

EFeet  .      . 

letters,  it  is  fastened  to  a  hook 
200  or  nail  about  6  feet  from  the 
floor,  and  about  20  feet  from 
the  chair  in  which  the  patient 
is  seated.  The  letters  of  the  20- 
foot  line  are  then  about  on  the 
level  with  the  patient's  eye. 
The  card  must  be  well  illumi- 
nated by  daylight  or  artificial 
light.  The  20-foot  distance  is 
not  necessary;  12  feet  will  an- 
swer, but  in  this  case  we  must 
bear  in  mind  that  the  patient 
should  read  several  lines  lower. 
Ahvays  examine  each  eye  sepa- 
i^ately.  Seat  the  patient  facing 
the  card;  direct  his  attention  to 
the  test-letters;  cover  the  left 
eye  with  a  small  card  and  ask 
him  to  read  on  the  test-card  as 
low  down  as  possible.  Note  the 
lowest  line  read  correctly  or  nearly  so,  and  then  cover 
the  right  eye  and  test  the  left  in  a  similar  manner. 
Reofister  the  finding^s  as  follows:  If  the  card  is  hung 


70 


C  B 

D  I.  N 

P  T  E  R50 

F  Z  B  D  £40 

O  F  L  C  T  G  30 

APEOZtFDZ     20 

HPRTVZBDFHEO    15 


VSTAOB  OLBPa* 


Fig.  57. — Reduced  illus- 
tration of  an  ordinary  card 
of  test-letters  for  measuring 
the  acuity  of  distant  vision. 


VISUAL    TESTS.  223 

at  20  feet  distance,  use  20  as  the  numerator  and  the 
number  of  feet  at  the  side  of  the  lowest  line  read  as 
the  denominator.  This  gives  \.\\q  visual  fraction.  For 
instance,  if  the  patient  reads  the  line  marked  40  feet 
(that  is,  consisting  of  letters  subtending  an  angle  of 
5'  at  40  feet),  his  visual  fraction  is  f  {).  Any  fraction 
less  than  \%  indicates  defective  vision. 

But  it  must  be  borne  in  mind  that  the  mere  fact  of 
the  patient  reading  the  f  ^^  litte  is  no  assiiratice  of  the 
absence  of  refractive  error.  The  patient  may  be 
hyperopic  and  astigmatic  (if  in  youth,  to  a  very  con- 
siderable extent),  and  still  read  the  \%  line  by  means 
of  his  accommodation,  and  it  is  this  very  extra 
strain  that  causes  the  distressing  asthenopic  symp- 
toms. This  can  be  definitely  determined  only  by  the 
use  of  a  mydriatic. 

If  the  patient  already  wears  glasses,  and  with  them 
he  cannot  read  with  each  eye  separately  |-^,  he 
should  consult  an  oculist.  If  there  is  considerable 
difference  of  vision  in  the  two  eyes,  there  is  great 
likelihood  of  eye-strain. 

If  the  symptoms  cannot  be  traced  to  any  other 
cause,  or  if  the  patient  uses  the  eyes  excessively  or 
viciously,  or  if  the  symptoms  are  especially  referred 
to  the  eye,  even  though  the  vision  appears  normal 
or  properly  corrected  with  glasses,  the  physician 
should  put  one  drop  of  a  2  per  cent,  homatropin  solu- 
tion into  one  eye  every  five  minutes  for  a  half  hour, 
and  then  if  the  vision  falls  to  any  great  extent  the 
patient  is  ametropic,  likely  hyperopic  or  astigmatic. 
Myopic  persons  without  astigmatism  see  about  as  well 
at  a  distance  under  a  mydriatic  as  with  the  accommo- 
dation functional. 


224  THE  EYE. 

If  the  patient  is  young  or  is  not  compelled  to  use 
the  eyes  in  his  daily  vocation,  and  complains  of  per- 
sistent eye-pain  or  headache  untraceable  to  other 
causes,  the  eyes  should  be  put  at  rest  under  atropin  for 
ten  days,  and  tested.  This  is  accomplished  by  the  in- 
stillation three  times  daily  for  two  days  of  one  drop  of 
a  I  per  cent,  solution  of  atropin  into  each  eye.  If  the 
vision  falls  under  the  mydriasis,  or  if  the  symptoms 
are  relieved,  the  diagnosis  of  ametropia  is  positive. 

Testing  Accommodation. — The  small  reading 
test-card  or  paper  is  brought  slowly  up  before  each 
eye  separately,  the  other  being  covered,  and  the 
patient  is  told  to  fix  his  gaze  on  type  of  about  the 
size  shown  in  the  following  paragraph: 

Measures  preventing  the  development  of  myo- 
c  pia  consist  in  tlni  careful  examination  of  chil- 

dren's eyes,  particularly  about  the  time  they  are 
to  start  to  school,  and  in  securing  the  best  hygi- 
enic conditions  for  them  during  their  school 
hours.  Good  ventilation,  properly  constructed 
desks,  and  sufficient  and  rightly  directed  light 

If  he  is  younger  than  21,  he  should  be  able  to  read 
the  type  easily  at  from  5  to  7  inches  distance,  other- 
wise he  is  considerably  hyperopic  or  has  some  extra 
disturbance  of  the  ciliary  muscle,  and  his  case  is 
one  for  an  oculist.  If  the  patient  is  middle-aged 
and  cannot  see  the  type  easily  at  10-12  inches,  he  is 
either  presbyopic  or  hyperopic,  and  is  in  need  of 
reading-glasses.  If  there  is  a  discrepancy  in  the 
reading-power  of  the  two  eyes,  the  case  is  especially 
one  for  an  oculist.  If  the  patient  has  very  poor  dis- 
tant vision,  but  can  read  the  type  easily  at  5  inches, 
he  is  a  myope.  If  the  patient  is  already  wearing 
reading-glasses  and  the  type  cannot  be  read  with  each 
eye  at  10-12  inches,  his  glasses  are  not  strong  enough. 


COLOR-JU./NDNESS.  22$ 

If  lie  cannot  read  tlic  type  with  his  glasses  at  a  dis- 
tance of  at  least  14  inches,  his  glasses  are  too  strong. 

Color-blindness. — Total  color-blindness  is  very 
rare.  In  such  cases  the  entire  solar  spectrum  ap- 
pears grayish.  Partial  color-blindness  is  generally 
congenital.  It  is  often  hereditary,  and  sometimes 
skips  several  generations.  The  discoverer  of  color- 
blindness was  Dalton,  a  distinguished  professor  of 
chemistry,  who  himself  was  color-blind,  a  fact  which 
he  ascertained  by  accident. 

Acquired  color-blindness  may  be  the  result  of 
disease  or  accident.  Defective  color-sense  often  ap- 
pears after  disease  of  the  optic  nerve,  and  is  a  par- 
ticular symptom  in  optic  neuritis  and  atrophy  due  to 
excessive  use  of  tobacco  and  alcohol.  However, 
central  color-blindness  may  be  seen  in  all  forms  of 
toxic  amblyopia.  A  peculiar  point  to  be  noted  in 
tobacco-amblyopia  is  the  fact  that  the  patient  may  be 
able  to  distinguish  colors  close  to  the  eye,  but  when 
they  are  farther  removed  he  is  color-blind,  partic- 
ularly for  green  and  red.  This  makes  it  quite  im- 
portant to  test  for  color-blindness  at  the  normal  signal 
distance  in  addition  to  the  skein-test  at  close  range. 
Color-blindness  is  sometimes  the  result  of  injury; 
occasionally,  after  blows  upon  the  head,  color-blind- 
ness is  noticed  in  one-half  the  field  of  vision  only,  the 
other  half  being  normal  in  its  color-perception. 

Partial  color-blindness  is  quite  common.  Statis- 
ticians tell  us  that  the  proportion  is  i :  25  among  males, 
and  I  :  400  among  females.  There  may  be  blindness 
to  blue,  yellow,  red,  or  green.  However,  the  colors 
that  most  often  fail  to  make  proper  impressions  are 
red  and  its  complementary  color  green.     These  colors 

15 


226  THE   EYE. 

do  not  appear  as  absolutely  black,  but  they  cannot 
be  distinguished  from  one  another  and  from  certain 
shades  of  gray  and  brown.  In  extreme  cases  there 
is  total  blindness  for  red  and  green,  and  even  the 
brightest  shade  of  red  cannot  be  distinguished  from 
green.  Unfortunately,  the  colors  most  often  at  fault 
are  those  selected  by  railroad  companies  and  naviga- 
tors as  their  signal  colors;  hence,  we  see  hovv'  im- 
portant it  is  for  the  employes  of  transportation  com- 
panies to  have  the  color-sense  absolutely  perfect. 

In  the  ordinar}^  Holmgren  test,  the  person  is  given 
a  test-skein  of  wool  of  a  light-colored  pink,  and  told 
to  select  (and  not  name)  from  a  mass  of  similar  skeins 
those  which  most  nearly  resemble  the  skein  to  be 
matched.  If  he  is  color-blind,  he  will  confuse  the 
grays,  the  greens,  the  pinks,  the  browns,  and  the 
reds.  As  a  confirmative  test  he  is  then  given  a  light, 
pure  green  skein  to  match  in  the  same  way.  It  is 
presupposed  that  the  examiner  is  not  at  all  color- 
blind. 

Dr.  William  Thomson  has  devised  a  convenient 
apparatus  for  testing  for  color-blindness,  which  has 
been  widely  adopted  by  railroad  examiners.  It  con- 
sists of  a  stick  to  which  numerous  bundles  of  yarn 
are  attached,  a  light  green  being  used  as  the  test- 
skein.  The  method  of  using  the  Thomson  stick  is 
described  by  its  author  as  follows:  Using  the  light- 
green  test-skein,  the  patient  under  examination  is 
asked  to  match  it  in  color  from  the  yarns  on  the 
stick,  which  are  arranged  in  alternate  green  and  con- 
fusion-colors, and  which  are  numbered  from  one  to 
twenty.  The  selection  of  ten  tints  is  required,  and 
the  examiner  notes  the  number  of  the  tints  chosen. 


TESTS   TOR   BLINDNESS.  227 

The  odd  iiiiiiibcis  arc  <;i'ccii  and  llic  even  ones  tlie 
confusion-colors.  If  the  patient  has  a  good  color- 
sense,  his  record  will  exhibit  none  but  odd  numbers; 
if  he  is  color-blind,  the  mingling  of  even  numbers 
betrays  the  defect.  To  distinguish  between  green- 
blindness  and  red-blindness,  the  rose-test  is  used, 
and  the  color-blind  patient  will  select,  indifferently, 
either  the  blues  intermingled  with  the  rose,  or,  per- 
haps, the  blue-greens  or  grays.  Finally,  the  red  test 
is  used  as  a  control.' 

There  are  other  color-tests,  but  these  two  are  suffi- 
cient for  practical  purposes.  The  field  for  vision  for 
different  colors  is  tested  in  the  same  manner  as  the 
field  for  white,  using  a  colored  object  instead  of  a 
white  one. 

Tests  for  Blindness. — Hysteric  amblyopia  is  not 
uncommon,  but  very  many  cases  so  diagnosed  are 
properly  the  sequence  of  asthenopia.  Malingering 
by  the  declaration  of  amblyopia  or  blindness  ma}-  be 
found  in  insurance-examinations  and  in  military  life, 
and  often  to  procure  damages  after  alleged  injuries. 
Many  ingenious  devices  have  been  adopted  to  expose 
the  simulant,  all  depending  upon  the  fact  that  in  or- 
dinary visual  perception  there  is  no  account  taken  of 
the  exact  participation  of  the  two  eyes.  If  we  hold  a 
book  before  the  patient's  eye  and  interpose  a  pencil 
in  front  of  the  eye  supposed  to  be  active,  the  reading 
will  be  slightly  interrupted  if  the  left  eye  is  ambly- 
opic; if,  however,  the  amblyopia  is  feigned,  the 
left  eye  will  escape  the  pencil  and  the  reading 
will  be  uninterrupted.  Another  way  is  to  interpose 
a  highly  convex  lens  in  front  of  the  eye  supposed 
to  be  good,  and  if  the  test-t}-pe  is  removed  beyond  the 


228  THE   EYE. 

focal  distance  of  the  lens  and  is  still  legible,  we  know 
that  the  other  eye  participates  in  vision.  The  pro- 
duction of  double  images  by  the  interposition  of 
prisms  also  proves  binocular  vision.  Still  another 
method  depends  upon  colored  letters  placed  upon  a 
dark  background  which  cannot  be  seen  through 
glasses  of  complementary  colors.  A  person  looking 
at  green-blue  letters  on  a  dark  ground  through  a  red 
glass  over  the  sound  eye,  and  a  white  or  green  glass 
over  the  alleged  blind  eye,  will  be  unable  to  see  the 
letters  if  the  allegation  is  true. 

THE  GENERAL  CARE  OF  THE  EYES  AND  SCHOOL- 
HYGIENE. 

The  care  of  the  eyes  in  earlier  childhood  is  as 
equally  important  as  later.  From  the  moment  of 
birth  the  eyes  should  be  carefully  watched. 

Ophthalmia  neonatorum,  a  disease  appearing  be- 
tween the  first  and  third  days  of  life,  and  commonly 
known  as  ' '  babies'  sore  eye, ' '  is  responsible  for  a 
large  proportion  of  blindness.  The  moment  the 
mother  or  nurse  notices  the  appearance  of  an  inflam- 
mation of  a  child's  eyes  during  the  first  week  of  life, 
a  physician  should  be  summoned,  and  his  directions 
as  to  repeated  cleansing  should  be  rigorously  carried 
out. 

Infants'  eyes  should  never  be  exposed  to  the 
direct  glare  of  the  sun,  either  indoors  or  outdoors. 
In  the  crib  or  bed  the  baby's  face  should  be  turned 
from  the  window.  When  out  in  its  coach  it  should 
be  protected  when  lying  down  by  a  parasol  or  awn- 
ing, preferably  lined  with  some  dark-colored  material 
that  will  not  reflect  the  lig^ht.     Young-  children  should 


rilR   DANCERS   ()/<    TJIE   KINDEKCAR-JViN.       229 

not  be  encouraged  to  play  with  toys  tliat  require 
close  inspection.  If  blocks,  letters,  or  picture-books 
are  allowed,  they  should  be  so  large  as  to  be  easily 
seen  at  some  distance  froui  the  eye.  Even  very  suiall 
infants  are  better  out  of  doors  on  a  clear  day,  and 
when  they  can  walk,  they  should  be  ronipiug  about  in 
gauies  or  lookiug  at  distant  objects,  rather  than  using 
their  eyes  at  close  range.  General  physical  exercise 
rather  than  ocular  and  intellectual  labor  is  desirable 
in  young  children. 

As  the  child  grows  and  associates  with  playmates 
or  schoolmates  every  precaution  should  be  used  to 
prevent  its  infection  from  granular  lids  and  acute 
conjunctivitis  ("pink  eye"),  as  well  as  from  other 
contagious  diseases.  It  must  not  be  allowed  to  u.se 
the  same  towel,  handkerchief,  or  drinking-mug  that 
is  used  by  its  companions,  and  it  should  especially 
be  restricted  from  playing  with  children  who  have 
' '  sore  eyes. ' ' 

The  Dangers  of  the  Kindergarten. — There  is  a 
very  fashionable  practice  now  prevalent  of  sending 
very  young  children,  particularly  when  restless  and 
hard  to  amuse,  to  so-called  kindergarten  schools, 
where  they  play  with  small  objects  or  look  at  pictures, 
or  sew  at  close  range.  This  is  a  distinctly  injurious 
custom.  Very  young  children  should  be  discouraged 
from  all  near  work,  and  in  da5^-nurseries  and  primary- 
schools  the  most  of  the  teaching  requiring  visual 
labor  should  be  by  large  pictures  and  charts  hung  at 
some  distance  from  the  pupils'  eyes. 

If  a  child  has  red  eyes,  holds  its  book  close,  com- 
plains of  not  being  able  to  see  at  a  distance,  looks  at 
objects  sideways  or  between  partially  closed  lids,  or 


230  THE   EYE. 

squints  or  complains  of  headache,  browache,  or  pain 
in  the  eyes,  it  is  the  parents'  or  teachers'  duty  to  send 
it  to  a  competent  oculist.  If  the  oculist  decides  that 
glasses  are  necessary,  they  should  be  put  on  at  once 
in  spite  of  any  foolish  prejudices,  for  they  will  save 
and  promote  the  physical  and  intellectual  develop- 
ment of  the  child  and  prevent  many  years  of  suffering 
and  perhaps  irreparable  ocular  disease. 

Young  children  with  defective  vision  or  hearing 
are  often  called  stupid  and  inattentive,  and  actually 
punished  for  physical  faults  which  should  have  been 
detected  and  remedied  long  before. 

The  question  is  often  asked,  "  When  shall  a  child 
begin  school  ?  "  This,  of  course,  depends  entirely 
on  the  child's  health  and  the  condition  of  the  eyes. 
If  the  eyes  are  defective  and  show  a  great  tendency 
to  astigmatism  or  myopia,  the  mental  education 
should  be  postponed  and  systematic  study  should  not 
be  started  until  the  person  is  twelve  years  of  age, 
when  the  ocular  tissues  become  more  resistant.  In 
the  meantime  the  child  should  be  instructed  judici- 
ously at  home  or  in  shortened  courses  at  school. 
Outdoor  exercise  and  properly  assigned  manual  labor 
should  be  urged.  If  the  child  is  of  poor  parentage 
and  must  go  to  public  school,  it  will  be  better  to  post- 
pone the  schooling  for  a  few  years  and  enter  later  a 
class  of  children  below  its  age,  explaining  to  teacher 
the  reason  of  the  deficiency  in  ediication. 

Ordinarily  a  healthy  child  with  normal  eyes  may 
begin  school  at  from  eight  to  ten  years  of  age.  It 
then  arrives  at  systematic  study  after  its  ocular  tis- 
sues are  well  formed.  Of  course,  if  the  proper  pre- 
cautions, of  which  we  have  much  to  say  later,   are 


CARE    OF  CHILD  RUN'S  EYES  AT  IIUMK.  23  I 

practised,  the  entrance  age  may  l^e  lowered  soniewliat. 
No  child  of  tender  years  shonld  be  enconraged  in 
prize  competitions;  in  fact,  it  wonld  be  better  if  there 
were  no  grading  in  the  primary  schools  other  than  by 
term  average.  The  ambitions  of  parents  sometimes 
lead  to  ruin  of  a  child's  eyes  and  health. 

Care  of  Children's  Eyes  at  Home. — Continuous 
close  work  is  most  detrimental  to  the  eyes  of  children. 
Sometimes  parents  allow  the  evils  of  school-life  to 
be  repeated  at  home.  No  provision  is  made  for 
proper  lighting  and  seats.  Children  are  often 
allowed  to  read  story-books  and  novels  as  much  as 
they  please,  and  until  late  at  night  in  a  poorly 
lighted  room  or  in  front  of  a  fireplace,  and  often  in 
stooping  or  recumbent  positions.  All  this  is  wrong. 
Such  children  are  generally  over-ambitious  in  school, 
and  not  only  should  be  compelled  to  take  intervals 
of  rest  from  close  v^ork  during  the  day,  but  also 
should  be  discouraged  from  using  their  eyes  in  read- 
ing, writing,  or  sewing  at  night.  If  some  home 
study  is  necessary,  the  proper  lighting,  chairs,  and 
desks  should  be  provided. 

The  pernicious  influence  of  modern  school-life 
upon  the  eye  as  well  as  upon  the  general  health  is 
not  sufficiently  recognized  by  parents  and  teachers. 
Nearly  all  knowledge  is  acquired  to  some  extent  by 
the  use  of  the  eyes,  and  if  the  proper  h5'gienic  pre- 
cautions in  vision  are  not  heeded,  the  evil  effects  of 
eye-strain  upon  the  whole  body  may  be  most  serious. 
With  the  advance  of  civilization  there  is  a  constant 
increase  of  visual  defects  and  of  general  physical 
degeneration  among  school-children.  The  causes 
are  many.     The  most  prominent  are:  imperfect  con- 


232  THE  EYE. 

struction  of  school-houses,  imperfect  lighting,  foul 
air,  crowding,  poor  ventilation,  long  hours  of  con- 
tinuous application  at  close  work  in  school  and  neces- 
sary extra  preparation  after  school-hours,  frequent 
and  trying  examinations,  and  poor  print  and  paper  in 
school-books. 

Until  recently  there  has  been  a  disregard  on  the 
part  of  public  authorities  and  educational  chiefs  of 
the  advice  of  physicians  in  matters  of  public  hy- 
giene. Happily  this  is  being  overcome  through  the 
efforts  of  the  intelligent  mass  of  the  community  and 
the  patriotic  efforts  of  the  physicians  themselves, 
who  have  often  given  advice  and  time  willingly  and 
without  compensation.  We  hope  soon  to  see  the 
time  when  all  persons  seeking  election  as  school- 
directors,  educational  trustees,  superintendents  of 
schools,  etc.,  will  be  subjected  to  a  non-partisan 
examination  or  be  compelled  to  show  qualification 
in  the  principles  of  school-hygiene. 

There  should  also  be  salaried  medical  inspectors, 
controlled  by  prominent  chiefs,  to  whom  they  will 
be  responsible  for  the  performance  of  their  duties. 
These  physicians  should  systematically  examine  the 
eyes  as  well  as  the  general  health  of  every  school- 
child  before  entrance  and  during  the  tender  years 
of  school-life.  It  is  essential  that  the  teachers  should 
be  instructed  in  all  the  elements  of  school-hygiene. 

The  Development  of  Ametropia  in  School-chil- 
dren.— The  eyes  of  a  child  at  birth  are  hyperopic 
and  ill-adapted  for  close  work.  The  ocular  tissues 
are  delicate  and  soft.  If  excessive  near-work  is 
allowed,  the  pressure  of  the  tense  ocular  muscles 
on  the  eyeball,  together  with  the  blood-soaking  of 


scjjoor.  HYGIENE.  233 

tissues  from  constant  or  prolonged  ciliary  conges- 
tion, causes  the  coats  of  the  eyeball  to  become  viti- 
ated and  pressed  out  of  shape,  and  refractive  error 
develops.  There  is  unanimity  of  opinion  in  the 
numerous  statistical  studies  upon  this  subject. 

Most  school-children's  eyes  are  defective  and  gen- 
erally astigmatic;  the  hyperojjic  eyes  outnumber  the 
normal  and  myopic  eyes,  particularly  in  early  school- 
life.  As  the  higher  grades  are  entered  high  myopia 
and  progressive  myopia  with  choroidal  disease  be- 
come more  and  more  numerous,  until  the  proportion 
of  near-sighted  eyes  in  some  of  the  higher  continental 
universities  is  as  high  as  50  per  cent.  Strange  to 
say,  in  the  development  of  myopia  starting  primarily 
in  the  hyperopic  eye,  emmetropia  is  seldom  attained, 
the  disease  progressing  from  hyperopia  to  myopia,  as 
it  has  been  aptly  said,  "through  the  turnstile  of 
astigmatism." 

In  this  country  the  development  of  myopia  has 
been  much  lessened  by  the  efforts  of  oculists  to  show 
the  intelligent  members  of  the  community  that  much 
eye-trouble  may  be  offset  by  regulation  of  study  and 
reading  and  the  use  of  proper  glasses,  with  frequent 
re-examination  of  all  children  who  show  any  symp- 
toms of  eye-strain.  However,  there  is  much  to  be 
accomplished  in  the  construction  of  school-buildings 
and  the  regulation  of  the  ocular  labor  in  schools. 

School-hygiene. — In  view  of  the  importance  of 
eye-strain  and  ametropia  in  retarding  the  intellectual 
and  physical  development  of  children  it  has  been 
thought  advisable  to  discuss  separately  each  of  the 
more  important  faults  that  are  found  in  modern 
school-svstems. 


234  THE   EYE. 

The  location  of  a  school-building  should  be  so 
chosen  as  to  secure  the  best  sanitary  environment, 
if  possible  on  a  wide  street,  remote  from  any  adjaceht 
high  buildings,  if  possible  in  the  center  of  a  lot  large 
enough  for  a  surrounding  campus,  or  playground. 
It  has  been  found  that  ocular  defects  are  always  more 
numerous  in  schools  on  narrow  streets  or  in  close 
proximity  to  high  walls,  and  also  that  children  on 
the  lower  floors  of  such  school-houses  have  the  worst 
eyes.  It  has  also  been  found  that  there  is  much  less 
myopia  in  the  primary  schools  of  rural  districts. 

The  light  should  enter  the  room  directly,  and  not 
by  indirect  reflection  from  an  adjacent  wall.  The 
northern  light  is  the  most  constant.  However,  the 
hygienic  advantage  of  having  the  sun  in  the  rooms 
during  some  portion  of  the  day,  as  is  afforded  by 
the  other  exposures,  is  not  to  be  overlooked.  Exces- 
sive sunlight  in  the  warmer  months  may  be  controlled 
by  the  use  of  awnings  and  shades.  An  oblong  room 
allows  better  lighting  than  a  square  room. 

The  windows  should  be  numerous  and  spacious, 
with  large  panes  of  glass,  which  should  be  kept  clean. 
They  should  be  so  placed  that  the  light  may  come 
from  the  left  or  from  the  left  and  rear  of  the  desks. 
Light  coming  from  the  right  produces  annoying 
shadows  of  the  pupils'  hands  and  arms  on  their 
books  and  papers.  Light  coming  from  the  rear  is 
obstructed  by  the  pupils'  backs  and  also  produces 
shadows.  Light  from  the  front  is  the  worst  of  all, 
as  it  may  be  so  dazzling  as  to  greatly  embarrass 
vision.  One  has  only  to  look  at  a  picture  hung 
between  two  windows  to  realize  this.  Overhead 
or   sky-lighting   is   an    excellent    form   of   securing 


riiK  scJiooj.-KooM.  235 

illumination,  but  it  is  only  practicable  on  the  top 
floors.  It  contributes  much  annoying  heat  in  warm 
weather  and  interferes  with  proper  heating  in  the 
winter.  Cross-lighting  by  windows  on  opposite  sides 
of  a  room  produces  very  annoying  shadows. 

There  should  be  at  least  one  square  foot  of  window- 
space  to  each  four  square  feet  of  floor-space.  How- 
ever, there  cannot  be  too  much  window-space,  as 
excessive  light  may  easily  be  controlled,  while  artifi- 
cial illumination  is  the  only  remedy  for  a  deficiency 
of  daylight.  It  must  be  remembered  that  the  lower 
floors  require  the  largest  window-space. 

The  dimensions  of  an  ideal  scFiool-room  o-iven 
by  Risley,  who  has  carefully  studied  this  subject,  are 
as  follows  : 

Feet. 

Height  of  ceiling 15 

Length  of  room 32 

Width  of  room 24 

Pier  or  blank  wall,  rear  of  room 4 

Pier  or  blank  wall,  front  of  room 4 

Space  allotted  to  group  of  windows 24 

Window-sill  from  floor  (bevelled) 3 

Top  of  window  from  floor 14 

Height  of  window II 

This  arrangement  affords  a  total  capacity  of  11,520 
cubic  feet,  or  256  cubic  feet  for  each  of  forty-five 
pupils. 

Tlie  sills  should  be  at  least  four  feet  above  the 
floor,  so  that  the  light  will  come  over  the  pupils' 
heads.  Light  coming  in  below  is  worse  than  useless, 
and  must  sometimes  be  shaded.  There  should  be 
no  more  wall-space  above  the  windows  than  neces- 
sary, and  the  sills  should  be  bevelled  to  admit  the 
maximum  amount  of  lieht. 


236  THE   EYE. 

The  window-shades  should  be  of  the  ordinary 
Holland  style,  either  light  gray,  buff,  cream,  yellow, 
light  blue,  or  green.  There  should  be  two  for  each 
window,  so  that  the  upper  or  lower  half  of  the  win- 
dow, or  both,  may  be  shaded  as  desired. 

The  walls  and  ceilings  of  a  school-room  should 
be  of  some  light  reflecting  color,  such  as  advised  for 
the  shades.  Colors  near  the  red  end  of  the  spectrum, 
such  as  terra-cotta,  absorb  too  much  light  to  be  used. 
Light-colored  woods,  such  as  oak,  are  preferable  to 
walnut  and  other  dark  woods  for  use  in  the  doors, 
window-frames,  book-cases,  etc.  There  should  be  as 
little  wall  decoration,  such  as  charts  and  pictures,  as 
possible,  and  a  minimum  of  blackboards. 

A  simple  test  to  determine  the  efficiency  of  the 
lighting  is  to  attempt  to  read  small  print  in  the 
remotest  corner  of  the  room  on  a  cloudy  day.  Arti- 
ficial lighting  should  never  be  needed  during  school- 
hours. 

The  desks  and  seats  should  be  so  arranged  in  re- 
lation to  the  windows  that  the  light  comes  from  the 
pupils'  left  or  from  the  left  and  behind.  Under  no 
circumstances  should  the  desks  face  the  windows. 
Some  arrangement  must  be  made  so  that  the  teacher 
will  not  confront  the  direct  glare  continuously.  The 
desks  and  seats  should  be  adjustable.  It  is  very 
wrong  to  make  children  of  all  sizes  sit  at  a  uniform- 
size  desk.  Let  the  average  size  desk  be  generally 
used,  but  for  oversized  or  undersized  children  the 
desks  should  be  properly  adjusted,  and  to  avoid  extra 
trouble  these  children  should  keep  the  same  seats 
during  the  entire  term. 

The  common  faults  are  unsuitable  shape  of  back, 


DESKS  AND   SEATS. 


^2>7 


too  great  a  distance  between  seat  and  the  desk,  dis- 
proportion in  the  height  of  seat  and  desk,  and  incor- 
rect shape  and  slope  of  the  desk. 

The  edge  of  the  desk  should  slightly  project  over 
the  edge  of  the  seat.  The  top  of  the  desk  should  in- 
cline downward  from  the  horizontal  about  ten  degrees 
toward  the  student,  and  be  low  enough  to  allow  the 


n 


Fig.  58. — Position  assumed  in  writing  with  the  desk  too  high. 


forearm  to  rest  without  raising  the  shoulder.  The 
seat  should  be  sufficiently  broad  to  support  almost 
the  whole  thigh,  and  close  enough  to  the  floor  to 
allow  the  sole  of  the  foot  to  rest  on  the  floor.  It 
should  be  slightly  concave,  to  prevent  slipping,  and 
horizontal  rather  than  inclined.  The  back  should  be 
so  curved  forward  as  to  support  the  loins  sufficiently 


238 


THE  EYE. 


and  to  make  it  easy  and  comfortable  for  even  weakly 
children  to  sit  upright. 

If  the  seat  is  too  high,  the  child  cannot  touch  the 
floor,  and  is  uncomfortable  and  does  not  get  proper 
aid  from  the  legs  and  feet  to  maintain  an  upright 
position.  If  the  desk  is  too  high,  the  elbow  can  only 
rest  by  curving  the  spine  and  raising  the  shoulder 
(Fig.  58).     The   work   is  also  brought  close  to  the 


Fig.  59. — Position  assumed  in  writing  with  the  desk  too  low. 

eyes  and  causes  extra  strain.  If  too  low,  the  child 
stoops  over  the  desk  and  becomes  round-shouldered 
(Figs.  59,  60).  This  position  also  necessitates  great 
strain  on  the  accommodation  and  compresses  the 
superficial  veins  of  the  neck,  leading  to  ocular  and 
cerebral  congestion  with  its  pernicious  consequences. 
Blackboards,  charts,  and  maps  are  valuable  aids 
in  instructing  children,  because  by  them  information 


BLACh'BOAKDS,    CHARTS,   AND   MAPS. 


239 


may  be  imparted  at  a  distance  and  the  strain  of 
accommodation  in  near  work  dispensed  with.  All 
fignring-  or  lettering  mnst  be  snfficiently  large  to  be 
perfectly  legible  in  any  part  of  the  room.  Even  to 
those  of  moderate  visnal  acnity,  snch  characters,  to  be 
read  at  a  distance  of  forty  feet,  should  be  at  least  one 


Fig.  60. — Comparative  diagram  showing  the  proper  position  at  a  desk, 
a;  the  position  when  the  desk  is  too  low,  b  ;  and  the  position  when  the  desk 
is  too  high,  c.     (After  Cohn.) 

and  one-half  to  two  incheshigh.  The  same  precautions 
should  be  exercised  in  writing  on  the  blackboards. 
If  these  requisites  are  observed,  then  when  a  pupil 
fails  to  see  the  contents  of  charts,  maps,  or  blackboards 
from  any  part  of  the  room,  it  is  certain  that  there 
is  a  serious  error  of  refraction  or  disease  of  the  eve 


240  THE  EYE. 

requiring  immediate  medical  attention.  Blackboards 
should  be  kept  clean  with  sponge  and  water,  and  as 
dark  and  as  free  from  gloss  as  possible.  There  is  not 
sufficient  contrast  of  the  white  chalk  on  a  very  dirty 
grayish-black  board,  on  which  only  a  common  eraser 
has  been  used.  White  boards  with  black  crayons, 
although  affording  a  greater  contrast,  necessitate  soil- 
ing of  the  fingers  to  such  a  degree  as  to  be  imprac- 
ticable. 

Copying  from  the  blackboard  should  be  avoided 
as  much  as  possible,  as  it  is  very  trying  to  the  eyes  on 
account  of  the  constant  change  of  focus  from  the  desk 
to  the  board.  Blackboards  and  charts  should  never  be 
placed  between  windows,  but  always  opposite  the 
source  of  light. 

Slates  are  unclean  and  unhygienic,  and  often 
afford  too  little  contrast.  Pencils  or  pen  and  ink  and 
dull  white  paper  are  suitable  substitutes. 

Regulation  of  Study. — In  the  lower  grades  es- 
pecially there  should  be  such  regulation  of  the  studies 
that  reading  or  writing  after  school-hours  is  unneces- 
sary. The  studying  should  be  done  in  school.  The 
curriculum  should  be  so  arranged  that  wherever  pos- 
sible oral  instruction  and  demonstrations  with  maps, 
charts,  or  blackboards  are  substituted  for  study  from 
books.  The  curriculum  of  primary  schools  should  be 
so  elastic  that  pupils  in  poor  health  or  with  defective 
eyes  may  be  excused  from  the  full  course  of  instruc- 
tion. Prize  competitions  or  term-examinations 
should  not  be  allowed  in  the  primary  schools.  Fre- 
quent intervals  of  rest,  such  as  are  afforded  by  conver- 
sations, lectures,  and  recesses,  are  very  desirable.     One 


sciioor.  iwoKs.  241 

daily  session  of  two  or  three  hours  is  snfTlcient  for  the 
smaller  eliildreii. 

Medical  examination  of  school-children  is  most 
desirable.  Kvery  child  should  show  a  medical  cer- 
tificate of  good  health  and  satisfactory  vision  before 
being  allowed  to  enter  school,  and  an  annual  re-exami- 
nation should  be  made  at  the  beginning  of  each  term. 
The  teachers  may  be  instructed  by  the  school  physi- 
cians in  the  elements  of  medical  examination  and  in  the 
grosser  tests  for  hearing  and  vision,  and  thus  become 
of  great  assistance  to  the  medical  staff.  Children 
with  faulty  eyes  should  be  sent  to  an  oculist  or  to  an 
ophthalmic  hospital  for  treatment  and  for  advice  as  to 
the  advisability  of  continuing  with  their  studies. 

School-books  should  be  small  enough  to  be  easily 
handled,  and  ought  to  be  printed  in  easily  legible  type 
on  dull-surface  paper.  Cohn  insists  that  in  schools  all 
books  should  be  forbidden  that  contain  smaller  type 
than  long  primer  (about  10  point)  and  a  less  interval 
than  one- tenth  of  an  inch  between  the  lines.  No  line 
should  be  over  four  and  one-half  inches  long,  nor 
contain  more  than  sixty  letters. 

The  following  remarks  apply  as  well  to  books  and 
papers  other  than  for  use  by  school-children. 

Type. — Heavy-faced  type  with  bold  strokes  is 
always  the  easiest  to  read.  What  are  known  as  8 
and  10  point  type  (each  point  representing  one-sev- 
enty-second of  an  inch)  are  common!}'  used  in  print- 
ing. Finer  type  necessitates  great  strain  on  the  ac- 
commodation, and  requires  that  the  page  be  held  too 
close  to  the  eye.  Coarser  type  increases  ocular  labor, 
and  often  lengthens  the  columns  and  lines.  The 
text  of  this  book  is  printed  in  small  pica  type,  which 

16 


242  THE   EYE. 

is  admirably  adapted  for  comfortable  reading.  Latin 
letters  are  infinitely  superior  to  Gothic,  and  the  Ger- 
mans are  fast  discarding  their  trying  type  in  maga- 
zines and  books  for  study  and  scientific  reference. 

Leading  between  the  lines  and  spacing  between 
the  letters  are  of  the  greatest  importance  in  securing 
legibility.  There  should  be  about  one-tenth  of  an  inch 
between  each  line  of  type.  Such  a  spacing  is  used 
on  this  page.  The  contrast  between  leaded  and  solid 
type  is  seen  in  the  following  paragraphs  in  8-point 
type: 

As  a  causative  factor  in  the  production  of  headache,  eye- 
strain is  by  far  the  most  important.  Anorexia,  dyspepsia, 
constipation,  heart-burn,  nausea,  repeated  attacks  of  vomiting, 
etc.,  represent  some  of  the  gastric  reflexes.  Many  cases  of 
obstinate  neurasthenia  are  of  ocular  origin.  Insomnia,  night- 
mare, chorea,  and  even  epilepsy,  have  often  owed  their  exist- 
ence and  perpetuation  to  uncorrected  eye-strain  in  some  form. 
The  multiformity  of  the  effects  of  eye-strain  can  be  properly 
realized  only  when  we  understand  how  vital  the  function  of 
vision  is  to  every  act,  emotion,  and  thought. 

Asa  causative  factor  in  the  production  of  headache,  eye-strain 
is  by  far  the  most  important.  Anorexia,  dyspepsia,  constipation, 
heart-burn,  nausea,  repeated  attacks  of  vomiting,  etc.,  represent 
some  of  the  gastric  reflexes.  Many  cases  of  obstinate  neurasthe- 
nia are  of  ocular  origin.  Insomnia,  nightmare,  chorea,  and  even 
epilepsy,  have  often  owed  their  existence  and  perpetuation  to 
uncorrected  eye-strain  in  some  form.  The  multiformity  of  the 
effects  of  eye-strain  can  be  properly  realized  only  when  we  under- 
stand how  vital  the  function  of  vision  is  to  every  act,  emotion,  and 
thought. 

The  length  of  the  line  is  of  the  greatest  impor- 
tance. The  old  quarto  page  should  be  discarded. 
No  line  should  extend  over  four  and  a  half  inches; 
and  in  large  books  it  is  infinitely  better  to  divide  the 
page  into  two  or  even  three  short  columns  with  an 
appropriate  blank  space  between   them.     The  long 


rj!E  s'j'Yi.i':  oi<  WKiTiNd.  243 

lines  necessitate  extra  rotation  of  the  ocnlar  muscles, 
and  are  therefore  fatiguing-  to  the  eye.  The  lines 
of  this  page  are  about  three  and  a  half  inches  long. 

The  paper  used  for  reading  matter  should  not  be 
glazed  nor  have  a  glaring  white  surface.  A  dull 
surface  of  some  slight  neutral  tint  is  preferable.  It 
is,  of  course,  necessary  to  use  a  good  paper  and  the 
best  ink  to  secure  clear  impressions.  Paper  should 
be  opaque,  but  this  does  not  necessitate  thickness, 
as  some  of  the  most' expensive  small  prayer-books  and 
Bibles  are  printed  on  very  thin  paper.  Curved  printed 
surfaces  should  be  avoided. 

The  greatest  offenders  in  regard  to  unsuitable  paper 
are  the  two  extremes — the  newspapers  with  coarse 
paper,  indistinct  impressions,  blurred  ink,  and  small 
type,  and  the  high-class  illustrated  magazines  and 
books  with  a  highly  finished  glossy  surface  to  take 
the  popular  half-tone  plate  impressions. 

The  style  of  writing  taught  is  of  less  importance 
than  the  arrangement  of  the  desk  and  the  position 
of  the  pupil.  So  long  as  the  upright  position  is 
maintained  and  both  eyes  are  equidistant  from  the 
paper  {i.  e.  the  paper  in  a  central  position)  it  makes 
very  little  difference  whether  vertical  or  slanting 
writing  is  practised.  The  pupil  may  be  allowed  to 
evolve  his  own  system  of  penmanship  if  the  essen- 
tials of  position  are  complied  with.  However,  it  is 
contended  that  vertical  writing  is  much  easier  taught 
and  is  more  legible.  The  belief  that  it  is  less  likely 
to  cause  astigmatism  is  based  on  theory. 

Overwork  of  the  Eyes. — The  eye  is  one  of  the  most 
accommodating  organs  in  the  human  economy,  and 
under  favorable  auspices  will  perform  an  unlimited 


244  ^-^^  ^^-^• 

amount  of  work;  in  consequence,  persons  frequently 
demand  of  this  delicate  organ  an  amount  of  labor 
never  expected  of  the  grosser  structures.  In  fact,  it 
is  popularly  believed  that  if  the  eyes  are  healthy,  read- 
ing, sewing,  and  other  near  work  are  passive  acts, 
and  that  the  eye  is  untiring,  and  never  becomes  ex- 
hausted. This  is  especially  true  if  glasses  have  been 
prescribed,  for  then  the  patient  is  more  than  likely 
to  blame  his  oculist  if  the  eyes  pain  when  over- 
worked. Persons  whose  occupations  necessitate 
much  ocular  labor  should  vary  their  duties  with 
intervals  of  rest.  The  clerk  who  is  confined  to  his 
desk  all  day  should  seek  pleasures  at  night  that  do 
not  involve  ocular  labor.  In  continued  reading  and 
sewing,  it  is  well  to  desist  at  short  intervals  and  fix 
the  gaze  on  some  distant  objects  and  to  close  the  lids 
repeatedly.  The  sensible  person  so  regulates  his 
duties  and  recreations  as  to  allow  his  eyes  their 
deserved  rest. 

Artificial  Liglnting. — Much  of  the  ocular  labor  of 
to-day  is  performed  under  artificial  illumination. 
Most  persons  are  so  employed  during  the  day  that 
much  of  their  reading,  sewing,  waiting,  and  other 
near  work  is  done  at  night.  This  is  particularly 
so  during  the  winter  months,  when  the  days  are 
short,  and  there  is  little  inducement  to  remain  out  of 
doors.  An  ' '  evening  at  home ' '  generally  implies 
for  both  adults  and  children  an  evening  of  ocular 
labor.  The  amount  of  eye-work  done  to-day  is 
greatly  in  excess  of  that  of  our  forefathers.  The 
scarcity  of  books  and  newspapers  and  the  insufficient 
means  of  illumination,  often  only  by  the  tallow  dip 
or  open  fire,  discouraged  the  people  of  the  olden  time 


ARTIFICIAL    LIGirriNG.  245 

from  reading  at  iiight.  To-day  artificial  ilhiniiiia- 
tioii  is  so  perfected,  and  books,  magazines,  and  news- 
papers are  so  abundant  and  cheap,  and  circulating 
libraries  are  so  many,  that  the  habit  of  reading  has 
grown  to  enormous  proportions. 

In  view  of  all  these  facts  the  study  of  artificial 
lighting  becomes  a  matter  of  great  interest  and  im- 
portance. The  main  sources  of  artificial  illumina- 
tion are  kerosene,  gas,  and  electricity,  all  of  which 
when  properly  employed  may  be  satisfactory.  The 
nearest  approach  to  perfect  illumination  is  that  light 
which  most  nearly  resembles  diffuse  daylight.  Such 
diffused  lighting  by  artificial  means  has  not  been 
practicable  in  dwellings,  and  the  best  that  is  gener- 
ally done  is  to  afford  several  sources  of  light  near 
which  different  members  of  a  family  may  read  with 
equal  ease. 

The  principal  questions  of  importance  in  artificial 
illumination  are  the  quantity  and  quality  of  the  light, 
its  steadiness,  the  vitiation  of  the  atmosphere  by  the 
products  of  combustion,  and  the  expense. 

The  proper  installation  of  iiglnts  in  dw^ellings, 
school-rooms,  stores,  and  workshops  is  a  matter  often 
neglected.  It  is  common  to  see  a  large  family  gathered 
about  a  single  gas-burner  so  placed  that  those  most 
remote  from  the  light  do  not  get  nearly  enough  illu- 
mination. This  condition  is  remedied  in  ordinary 
dwellings  by  having  as  many  sources  of  light  as  are 
necessary  to  allow  each  reader  sufficient  illumination 
without  annoying  any  of  .the  others.  In  assembly 
rooms,  stores,  workshops,  etc.  these  difficulties  are 
not  so  easily  corrected. 

Besides  the  expense  and  necessary  vitiation  of  the 


246  THE  EYE. 

atmosphere,  the  proper  arrangement  of  the  lights  is 
often  very  troublesome.  Sometimes  the  light  may 
be  distributed  from  overhead  by  reflectors,  which  also 
may  act  as  ventilators.  In  ordinary  cluster  illumina- 
tion, even  distribution  is  impossible.  Those  nearest 
the  light  receive  the  most  illumination,  but  suffer 
from  radiation  of  heat,  and  in  many  portions  of  the 
room  annoying  shadows  are  cast.  If  in  addition  to 
the  central  cluster  extra  lights  are  used,  these  may 
aggravate  the  annoyances  and  in  some  cases  shine 
directly  into  the  eyes  of  some  of  the  occupants  of 
the  room.  If,  for  instance,  charts  or  blackboards  are 
especially  illuminated  by  extra  unshaded  lights,  the 
writing  thereon  is  read  only  with  the  greatest  dif- 
ficulty. In  illumination  from  both  sides  by  single 
flames,  persons  who  receive  light  from  the  right  are 
annoyed  by  shadows  of  the  hand  and  head.  If  the 
light  is  only  from  the  left,  then  some  of  the  occu- 
pants of  the  room  will  be  annoyed  by  shadows  cast 
by  their  own  bodies,  and  those  remote  from  the 
sources  of  illumination  will  receive  too  little  light, 
and  if  the  amount  of  illumination  is  raised  to  pre- 
vent this,  those  nearest  will  be  dazzled  by  the  in- 
creased light.  Illumination  by  individual  shaded 
lights  for  each  occupant  of  the  room  may  be  used, 
but  this  entails  great  expense,  and  unless  incandes- 
cent electric  lamps  are  used  there  is  too  much  heat 
given  off"  and  the  vitiation  of  the  atmosphere  is  very 
great. 

Indirect  illumination,  by  throwing  part  of  the  light 
on  suitably  colored  walls  and  ceilings  from  which  it  is 
reflected  diffusely  over  the  lower  part -of  the  room, 
has  been  used  with  success  both  in  this  country  and 


IL  r.  UMINA  TING-  GAS.  247 

abroad,  and  deserves  more  attention  than  has  been 
accorded  to  it  by  architects  and  builders. 

The  different  illuminants  will  be  discussed  sepa- 
rately in  a  general  way  rather  than  by  technical 
photometric  study. 

Kerosene  is  the  principal  illuniinant  of  rural  com- 
munities and  among  the  middle  and  lower  classes. 
Its  cheapness  is  a  great  point  in  its  favor.  The  bril- 
liant light  of  the  modern  lamp  when  properly  shaded 
by  a  slightly  bluish  chimney  or  shade  to  absorb  an 
excess  of  yellow  rays  is  very  satisfactory,  and,  in 
fact,  is  preferred  by  many  students  and  other  literary 
workers  to  all  other  kinds  of  illumination.  The 
principal  objections  are  the  heat,  the  trouble  in  filling 
and  keeping  clean,  the  danger  of  explosion  and  fire 
if  upset,  the  odor,  and  the  great  vitiation  of  the 
atmosphere.  One,  two  or  three  persons  working  in  a 
large,  well- ventilated  room  may  be  very  comfortable 
with  a  coal-oil  lamp,  but  in  a  large  assembly-room 
in  which  many  lamps  are  necessary  and  some  are 
always  smoking,  vitiation  of  the  atmosphere  is  great. 

Illuminating-gas  has  been  a  great  convenience,  but 
also  the  ruination  of  many  eyes.  As  usually  furn- 
ished in  cities,  it  has  a  great  excess  of  yellow  rays, 
which  are  very  injurious.  The  flame  of  the  old-fash- 
ioned "fish-tail"  burner,  blown  by  every  current 
of  air  so  as  to  be  continually  flickering,  is  a  most 
pernicious  form  of  lighting;  yet  for  years  many 
families  have  read  at  night  by  this  means.  The 
vitiation  of  the  atmosphere  is  very  considerable  in 
gas-combustion,  and  coal-gas  is  dangerous  and  more 
expensive  than  kerosene,  but  not  so  hot  and  much 
more   convenient.     The   principal   improvements  in 


248  THE  EYE. 

gas-lighting  are  the  Argand  burner  and  the  Bunsen 
burner,  heating  a  patented  composition-mantle  to 
incandescence. 

The  Argand  burner  is  very  easily  controlled,  and 
gives  an  excellent  light,  especially  when  properly 
shaded.      It,  however,  lacks  intensity  and  is  very  hot. 

The  incandescent  mantle  is  without  doubt  the 
greatest  improvement  in  gas-lighting.  It  gives  a 
white  light  resembling  daylight,  and,  under  proper 
adjustment  and  regulation,  of  far  greater  volume  (50- 
70  candle-power)  than  any  other  gas  burner,  is  not  so 
hot,  and  does  not  consume  as  much  gas,  and  hence 
does  not  cause  such  vitiation  of  the  atmosphere.  The 
expense  of  installation  is  more  than  offset  by  the  sav- 
ing in  gas.  It  is  too  intensely  brilliant  to  be  placed 
on  a  level  with  the  eye,  unless  it  is  shaded  with 
ground  glass,  opaque  glass,  porcelain,  or  other  like 
material  of  a  neutral  tint.  If  it  is  desired  to  light  a 
whole  room,  the  burner  should  be  suspended  quite 
high,  and  should  be  unshaded  beneath.  Holophane 
globes  or  reflectors  will  aid  in  deflecting  most  of  the 
rays  downward. 

Electricity  is  undoubtedly  the  coming  means  of 
artificial  illumination. 

The  arc  light  is  unsurpassed  for  lighting  large 
areas.  It  is  almost  colorless,  and  its  spectrum  most 
nearly  resembles  that  of  sunlight.  It  is  easily  con- 
trolled, and  is  becoming  more  and  more  inexpensive. 
Almost  any  candle-power  up  to  1000  may  be  obtained. 
The  arc  light  is,  of  course,  too  dazzling  and  irregular 
for  ordinary  interior  lighting,  unless  very  much  modi- 
fied by  shading. 

The  incandescent  light  is  now  in  general  use  in 


DU'FERENT  ILLUMINATINd   A  (J  E  NTS. 


249 


the  cities  of  this  country,  and  many  of  the  suburban 
towns  have  their  own  electric  light  plants.  It  is 
being  furnished  cheaper  each  year,  and  on  account  of 
convenience  it  is  deservedly  a  most  popular  form  of 
illumination.  It  is  controlled  and  lighted  very  read- 
ily, and  is  virtually  as  portable  as  a  candle  and  may 
be  used  for  decorative  purposes.  It  gives  a  maxi- 
mum amount  of  light  with  a  minimum  of  heat,  and 
this  without  vitiation  of  the  atmosphere — a  most  im- 
portant advantage.  ■  The  ordinary  incandescent  light 
is  called  16  candle-power;  but  in  practice  its  illumin- 
ating power  falls  to  between  i'2  and  14  candle-power. 
This  is  sufficient  only  for  individual  purposes,  but 
the  amount  of  light  desired  may  readily  be  multiplied 
to  large  proportions  by  the  installation  of  extra  lights. 
The  annoying  glare  of  the  incandescent  coil  may  be 
remedied  by  an  opalescent  shade. 

Comparison  of  the  different  illuminating  agents 
is  given  in  the  following  table,  taken  from  the  Lon- 
don Jojirnal  0/  Gas-lighthig^  January  18,  1898  : 


bs 

bs 

«S" 

u 

c 

u 

0 

.S-E 

.0    g    Q, 

•d 

3 

h  0 

lluminat 
power    ( 
practica 
use). 

onsiimpl 
of  illumi 
ingagen; 
hour. 

X 

^  bO 
U5 

'-* 

" 

^ 

-Q 

Candles. 

Cu.  ft. 

Calories. 

Pence  (=  2 
cents). 

Coal-gas. 

Flat  flame. 

30 

14.09 

1995 

0.768 

" 

Argand. 

20 

7.06 

1000 

O.3S4 

" 

Regenerative. 

III 

14.41 

2042 

0.780 

" 

Incandescent. 

50 

3-53 

500 

0.192 

Spirit. 

a 

30 

3.48  cu. in. 

31S 

0.240 

Petroleum. 

l^      "  burner 

30 

6.57  cu.  in. 

960 

0.264 

" 

Incandescent. 

40 

3.05  cu.  in. 

550 

0.120 

Acetylene. 

60 

1.27  cu.  ft. 

534 

0.264 

Electricity. 

Incandescent. 

16 

48  Watts 

41.4 

0.348 

Arc. 

600 

258  Watts 

222 

1.860 

250 


THE  EYE. 


Acetylene  produces  a  brilliant  and  in  fact  dazzling 
white  light,  and  on  account  of  the  small  amount  con- 
sumed it  is  not  expensive  and  there  is  a  small  amount 
of  effete  materials  of  combustion.  It  is,  however, 
very  dangerous  and  liable  to  explode,  and  is  chiefly 
used  in  bicycle  and  carriage  lamps.  The  danger  of 
explosion  begins  when  the  mixture  of  acetylene  with 
air  is  at  the  proportion  of  i  to  26,  and  it  ends  at  i  to  4, 

Prismatic  Devices. — In  older  school-houses  that 
for  financial  reasons  cannot  be  abandoned,  and  in  office- 


FlG.  61. — A  plate  of  glass  prisms. 

and  store-buildings  where  land  is  so  valuable  that 
the  buildings  must  be  high  and  contain  many  inside 
rooms  insufficiently  lighted,  the  problem  of  lighting 
is  a  perplexing  one.  The  disadvantages  of  using  the 
eyes  continually  in  an  artificial  light,  the  heat  and 
vitiation  of  the  atmosphere,  and  the  expense  have  all 
been  considered,  and  need  no  further  discussion  here. 
Any  plan  that  will  avoid  or  that  will  even  partly 
overcome  these  difficulties  should  be  earnestly  advo- 
cated. 

Within   the    last  few  years  several  manufacturers 
have  placed  on  the  market  plates  of  glass  which  are 


PRISMA  TIC  IJI:  VICES. 


251 


SO  constructed  that  they  contain  a  combination  of 
prisms  (Fig.  61)  which  will  bend  rays  of  light  from 
overhead  and  diffuse  them  at  any  angle.     Sometimes 


Fig.  62. — An  improperly  lighted  room  on  a  narrow  street. 

curved   surfaces   are   incorporated    with    the   prisms. 
By    these   prismatic    plates   the    insufficient   perpen- 


Fig.  63. — The  same  showing  improvement  in  lighting  by  prismatic  devices. 

dicular  light  of  a  deep  light-well  or  of  a  narrow 
street  lined  with  high  buildings  may  be  so  refracted 
that  it  may  be  used  to  illuminate  the  darkest  inte- 


2^2  THE  EYE. 

'riors  (Figs.  62  and  63).  The  prisms  may  be  inserted 
in  ornamental  window  panes  or  placed  in  the  form 
of  canopies  inclined  a  few  degrees  from  the  ver- 
tical; or  in  cases  of  cellars  and  basements  they  may 
be  used  in  the  form  of  mosaic  tiling  and  be  assisted 
by  a  second  interior  screen.  These  prisms  are  inex- 
pensive and  ornamental,  and  are  soon  paid  for  in 
the  saving  of  gas  or  electricity,  besides  furnishing 
illumination  infinitely  more  healthful  to  vision.  A 
similar  arrangement  of  prisms  is  also  utilized  in  glass 
globes,  called  holophanes,  for  gas,  oil,  or  incan- 
descent lights  suspended  overhead.  These  globes 
deflect  most  of  the  rays  of  light  downward. 

The  necessary  hygienic  precautions  in  reading 
include  the  selection  when  possible  of  large  type, 
sufficiently  spaced,  unglazed  paper,  and  short 
columns.  These  requisites,  of  course,  do  not  apply 
to  cheap  newspapers,  but  may  be  enforced  in  maga- 
zines and  books.  Sufficient  illumination  is  equally 
necessary,  and  of  no  less  importance  is  the  posi- 
tion of  the  reader,  the  position  of  the  book,  and  the 
relation  to  the  source  of  the  illumination.  The  posi- 
tion of  the  reader  should  always  be  upright,  leaning 
slightly  backward,  with  the  head  erect,  and  the  book 
held  nearly  on  a  level  with  the  eyes,  or  if  it  is  a 
heavy  volume  it  may  be  set  in  a  portable  and  adjust- 
able book-rest  or  placed  on  a  table  or  desk  in  such 
position  that  the  top  and  bottom  of  the  page  will  be 
equidistant  from  the  eye.  The  closer  objects  are  held 
to  the  eye  the  more  muscular  and  accommodative 
strain  is  necessitated  in  near  work.  Unfortunately, 
the  common  tendency  is  to  read  and  sew  at  close 
range,  even  when  not  necessary  for  clear  vision. 


NKCKSSARY  PA'/iCA ( r/'/o/VS   IN  READINC.        253 

The  proper  reading  distance  is  about  fourteen 
inches  from  the  eye;  but  no  type  should  be  used 
that  is  not  clearly  legible  at  twenty  inches.  Highly 
near-sighted  persons  often  hold  their  reading-mat- 
ter very  close  to  the  eye,  and,  while  reading  at 
their  far-point  without  the  aid  of  accommodation,  to 
secure  binocular  vision  they  put  such  tension  on  their 
muscles  of  convergence  that  serious  results  may  fol- 
low. Fatigue  of  the  ocular  muscles  often  produces 
as  uncomfortable  symptoms  as  uncorrected  ame- 
tropia. 

The  head  should  be  held  erect  in  reading  because 
in  this  position  there  is  less  liability  to  ocular  conges- 
tion. 

The  book  should  be  held  nearly  on  a  level  with 
the  eyes.  Continued  downward  rotation  of  the  eyes 
is  very  fatiguing,  and  there  is  an  inclination  to  stoop 
the  shoulders  before  many  minutes.  Ultimately 
round-shoulders  and  contracted  chest  are  produced. 

The  light  should  be  on  a  level  with  the  top  of  the 
head  or  above  the  head,  and  should  illuminate  over 
the  left  shoulder.  When  several  persons  are  seated 
around  a  table  or  a  long  desk,  and  by  unalterable 
architectural  reasons  all  cannot  secure  the  most 
advantageous  position  in  relation  to  the  light,  the  use 
of  eye-shades  is  often  of  great  help. 

Reading-  in  a  recumbent  position  is  a  pernicious 
habit,  and  is  particularly  dangerous  during  conva- 
lescence from  illness  or  when  physically  tired.  If  there 
is  fatigue  or  a  tendency  to  drowsiness  all  close  work 
should  be  suspended,  for  in  this  condition  accommo- 
dation and  convergence  are  only  effected  by  continual 
exercise  of  will-power,   and  much  nervous  energy  is 


254  ^-^^  ^^'^■ 

lost.  When  a  person  is  tired  or  drowsy  there  is  a 
constant  tendency  for  accommodation  and  conver- 
gence to  relax;  instead  of  these  acts  being  automatic, 
there  is  distinct  consciousness  of  an  effort  to  maintain 
them.  In  fact,  when  one  is  distinctly  sleepy,  instead 
of  the  normal  muscle-balance,  there  is  sometimes 
actual  divergence. 

In  the  recumbent  position  there  is  extraordinary 
strain  on  the  muscles  of  downward  rotation,  besides  a 
difficulty  in  adjusting  the  book  for  proper  illumina- 
tion. Again,  the  head  is  often  so  bent  as  to  encour- 
age ocular  congestion.  If  one  must  read  in  the 
recumbent  position,  the  book  should  be  placed  against 
a  pillow  where  it  will  be  well  illuminated,  and  the 
reader  should  lie  on  the  side  with  his  face  opposite  to 
the  page  at  a  comfortable  reading  distance. 

Constant  looking  upward  is  quite  as  fatiguing  as 
reading  in  the  recumbent  position,  as  any  one  will 
bear  witness  who  has  gazed  for  a  long  time  at  the  paint- 
ings in  some  of  the  large  Continental  art  galleries. 
There  is  a  peculiar  affection  of  the  ocular  muscles, 
known  as  "  miners'  nystagmus,"  which  is  caused  by 
the  constant  upward  gaze  while  at  work  in  the  supine 
position  in  coal-mines.  In  this  condition  the  sta- 
bility of  the  ocular  muscles  is  impaired,  and  there  is 
constant  oscillation  of  the  eyes. 

Reading  in  cars  or  carriages  is  injurious  to  the 
eyes.  Because  of  the  constant  jolting,  the  distance  be- 
tween the  type  and  eye  is  continually  changing,  neces- 
sitating frequent  and  abrupt  accommodative  adjust- 
ments. Besides  this  fault,  there  is  often  very  poor  illu- 
mination in  the  conveyances.  However,  at  the  present 
day  the  better  class  of  railroads  have  improved  these 


THE   El'I'EC'I'S    OF  S/MOA'IAra  AND   DRINKING.    255 

conditions;  there  is  sufficient  lighting,  and  by  mak- 
ing better  roadbeds  and  furnishing  better  balanced 
cars  with  more  numerous  springs,  they  have  reduced 
the  jolting  to  a  minimum.  In  some  of  the  modern 
cars  with  incandescent  lights  for  each  section,  read- 
ing is  not  at  all  uncomfortable.  If  reading  in  jolting 
cars  is  absolutely  necessary,  it  is  a  good  plan  to  use  a 
card  to  be  placed  under  each  line,  moving  it  down  the 
page  as  the  reading  progresses. 

Sewing  and  embroidery  require  the  most  trying 
ocular  labor  and  the  best  conditions  of  illumination. 
When  possible,  all  such  work  should  be  avoided  at 
night,  and  working  on  black  goods  by  artificial  light 
should  be  absolutely  forbidden. 

Engravers  need  not  be  told  the  necessity  of  bright 
daylight,  as  they  soon  find  any  other  illumination 
incompatible  with  fine  workmanship.  They  often 
need  enlightenment,  however,  on  the  necessity  of 
resting  their  eyes  at  frequent  intervals  during  their 
working-hours.  All  persons  doing  fine  eye-work 
should  be  accurately  fitted  with  glasses  if  they  are  at 
all  ametropic. 

The  Fiabit  of  wearing  veils  is  likely  responsible 
for  some  deterioration  of  vision,  particularly  if  they 
are  very  thick  or  dotted.  These  articles  are  often 
necessary  to  protect  the  face,  to  keep  the  hair  smooth, 
or  to  maintain  headgear  in  position.  In  such  cases, 
a  thin  veil  with  a  very  large  mesh  will  answer  all 
these  purposes  without  interfering  with  vision. 

The  effects  of  smoking  and  drinking  on  the  eyes 
are  often  exaggerated.  Of  course,  if  there  is  such 
excess  practised  that  the  whole  system  is  affected,  the 
eyes  will  participate  in  the  resultant  morbid  processes. 


256  THE  EYE. 

Again,  in  some  persons  there  is  a  special  idiosyncrasy 
to  alcohol  and  tobacco,  and  often  in  cases  of  partial 
blindness  apparently  due  to  what  is  known  as  toxic 
amblyopia,  the  amounts  of  tobacco  and  stimulants 
used  have  not  been  large,  yet  when  these  sub- 
stances have  been  discontinued  vision  has  been  re- 
stored. Such  patients  should,  of  course,  give  up 
forever  both  habits.  A  particular  danger  of  tobacco- 
smoke  is  its  irritating  action  on  the  conjunctiva, 
particularly  when  the  smoking  is  done  indoors 
while  reading.  The  smoke  curls  about  the  face 
and  enters  the  eyes,  causing  great  irritation  and 
blurring  of  vision. 

Relation  of  thie  Eyes  to  tine  General  Health. — It 
is  a  great  mistake  to  consider  the  visual  apparatus  as 
a  separate  organization.  It  is  intimately  connected 
with  the  whole  human  economy.  If  there  is  a  defi- 
cient blood-supply  or  nervous  exhaustion  or  perver- 
sion, if  the  secretions  are  abnormal,  in  fact,  if  there 
is  any  serious  functional  or  organic  change  in  the 
body,  the  eyes  may  participate  in  the  evil  conse- 
quences; and  in  the  same  way  visual  defects  may  in- 
fluence the  whole  constitution.  Those  measures  and 
modes  of  life  which  are  conducive  to  general  health 
and  vigor  will  be  beneficial  in  maintaining  ocular 
health  and  vitality.  Persons  who  seek  to  preserve 
their  vision  all  through  life  must  not  only  observe  the 
laws  of  ocular  hygiene,  but  also  those  of  general  phys- 
ical and  mental  hygiene,  such  as  are  .set  forth  in  the 
other  chapters  of  this  book. 


SPECTACLES  AND    E  YE  (J LASSES.  2.57 

SPECTACLES  AND  EYE-GLASSES. 

The  invention  of  spectacles  has  been  atlribiited 
to  two  Italians,  Alexander  da  vSpina  and  his  contem- 
porary, Salvinus  Arniatus,  and  to  Roger  Bacon,  all  of 
whom  lived  in  the  thirteenth  century.  On  the  tomb- 
stone of  Arniatus  is  said  to  be  inscribed,  "  The  In- 
ventor of  Spectacles."  From  other  sources  it  is  con- 
tended that  spectacles  were  introduced  into  Europe 
through  the  works  of  Alhazan,  a  Saracen,  who  died 
in  1038  A.  D.  It  is  thought,  however,  that  both 
concave  and  convex  lenses  were  used  by  the  Chinese 
long  before  this.  Seneca  and  Pliny  seem  to  be  famil- 
iar with  some  of  the  properties  of  lenses,  and  there 
is  a  legend  that  Emperor  Nero  was  near-sighted  and 
used  a  concave  precious  stone  (emerald)  to  assist  his 
distant  vision.  It  is,  however,  only  in  the  latter  half 
of  the  nineteenth  century  that  the  wearing  of  glasses 
has  become  universal,  and  that  the  various  mechan- 
ical improvements  leading  up  to  the  present  high 
standard  of  excellence  have  been  made.  Fitting 
glasses  upon  scientific  principles  was  never  at  all  gen- 
erally adopted  until  the  labors  of  Bonders  and  Snellen 
had  evolved  a  rational  method  of  examining  defec- 
tive eyes  and  prescribing  correcting  lenses.  Before 
their  time  all  this  was  largely  a  matter  of  guess-work, 
often  left  to  spectacle-vendors  ;  and  simple  convex 
and  concave  spherical  lenses  with  large  increments 
of  strength  were  used.     Cylinders  were  not  made. 

The  province  of  the  optician  is  solely  to  grind 
and  fit  glasses.  There  is  a  class  of  persons  call- 
ing themselves  "scientific  opticians,"  "refracting 
opticians,"  "  ophthalmists,"  and  the  like,  who,  with- 
out even  serving  the  apprenticeship  of  a  skilled  opti- 

17 


258  THE  EYE. 

cian,  without  the  slightest  medical  training,  and  with 
very  little  or  no  mechanical  knowlege,  undertake  to 
prescribe  glasses  as  well  as  to  sell  them.  They  adver- 
tise "eyes  examined  free,"  and  sometimes  rapidly 
travel  from  town  to  town  calling  themselves  "doctor" 
or  ' '  professor. "  It  is  hardly  necessary  to  reiterate  that 
it  is  dangerous  to  intrust  the  care  of  such  delicate  and 
intricate  organs  as  the  eyes  to  a  non-medical  person 
who,  working  without  a  fee,  has  only  an  interest  in 
the  sale  of  glasses,  which,  whether  needed  or  not, 
proper  or  improper,  may  be  urged  on  the  unsuspect- 
ing patient.  In  no  case  is  an  optician  the  proper 
person  to  prescribe  glasses.  This  is  the  business  of 
the  oculist,  who  is  an  educated  physician,  and  has 
had  long  experience  in  medical  colleges,  clinics,  and 
hospitals,  and  who  is  devoting  his  life  to  the  study 
of  his  profession.  He  alone  is  capable  of  compre- 
hending the  influence  of  the  general  systemic  condi- 
tion on  the  eyes,  and  of  defective  eyes  on  constitu- 
tional disturbances.  Often  glasses  are  prescribed  for 
definite  therapeutic  purposes  other  than  improvement 
in  vision.  The  optician  is  unacquainted  with  the 
minute  anatomy  and  physiology  of  the  eye  and  its 
physical  and  psychical  relations  with  the  whole  organ- 
ism. He  is  not  skilled  in  the  broad  science  of  medi- 
cine, of  which  ophthalmology  is  only  a  small  part. 

The  true  optician  has  no  pretensions  other  than 
the  skilful  grinding  and  adjustment  of  lenses.  To  be 
a  competent  workman  he  also  devotes  his  life  in  con- 
stant endeavor  to  improve  the  mechanical  construc- 
tion of  his  products,  making  eye-glasses  and  spectacles 
more  sightly  and  comfortable.  Too  great  stress  cannot 
be  laid  on  the  importance  of  a  good  optician.     The 


SPECTACLE-LENSES.  259 

results  of  all  the  careful  work  of  an  oculist  may  be 
set  aside  by  careless  and  incompetent  manufacture  and 
fitting  of  glasses.  It  is  a  safe  rule  to  patronize  only 
those  opticians  who  do  not  attempt  to  examine  eyes, 
but  confine  themselves  strictly  to  grinding  and  fitting 
glasses — in  other  words,  purely  "prescription  special- 
ists." Such  men  may  charge  more  for  their  material 
and  work  than  the  prices  advertised  by  "  refracting 
opticians,"  but  the  worth  is  in  the  construction  and 
fitting,  and  such  articles  will  be  cheaper  ultimately. 
Besides,  the  patient  who  is  ignorant  of  the  proper 
charge  need  not  fear  imposition,  such  as  is  often 
practised  by  "refracting  opticians."  Reliable  opti- 
cians are  sustained  only  by  the  recommendation  of 
prominent  oculists,  and  must  act  honorably  or  their 
support  will  soon  be  withdrawn. 

As  a  general  rule,  spectacles  are  preferable  to 
eye-glasses,  and  should  be  used  when  there  is  much 
astigmatism,  or  when  the  nose  is  not  properly  shaped 
for  the  correct  adjustment  of  eye-glasses.  The  objec- 
tions urged  against  spectacles  are  based  on  esthetic 
grounds  and  upon  the  uncomfortable  pressure  they 
may  make  on  the  nose  and  behind  the  ears.  A  well- 
fitted  pair  of  gold  frameless  spectacles  is  infinitely 
neater  looking  than  eye-glasses  pulled  out  of  shape 
by  a  cord  or  chain  hanging  over  the  ears  and  face. 
If  heavy  frames  are  ordered  and  the  spectacles  hurt 
the  ears  or  nose,  they  are  not  fitted  properly,  and  the 
optician  should  be  consulted  immediately. 

Spectacle-lenses  are  made  of  clear  flint  or  crown 
glass.  There  is  no  therapeutic  virtue  or  extra  dura- 
bility in  the  so-called  and  much  advertised  "  pebble 
glasses, "  "  rock-crystal  glagses, ' '  etc.    All  respectable 


26o  THE  EYE. 

opticians  use  for  the  purpose  of  grinding  lenses  the 
best  glass  that  they  can  buy.  The  cost  of  the  glass 
is  small,  and  they  could  not  afford  to  waste  skilled 
and  valuable  labor  on  poor  material. 

Spectacle-frames  are  made  of  gold,  steel,  silver, 
and  aluminum.  The  best  and  most  serviceable 
material  is  14-karat  gold.  It  has  superior  qualities 
of  temper,  adaptability  to  shaping,  and  durability, 
and  should  be  used  when  possible.  Ultimately  14- 
karat  gold  frames  will  prove  the  cheapest,  but  when 
they  are  not  practicable  on  account  of  expense,  the 
next  choice  is  lo-karat  gold  or  steel.  Although  steel 
may  rust,  it  is  preferable  to  silver  or  aluminum  on 
account  of  its  superior  hardness  and  temper.  Rubber 
and  shell  are  light,  but  too  brittle  for  use  in  spectacle- 
frames. 

Contrary  to  popular  idea,  within  certain  limits,  the 
heavier  the  bridge  and  temple-pieces  of  spectacles  the 
more  comfortable  they  are.  Heavy  temples  are  rigid 
and  keep  their  shape  better,  as  they  stay  on  the  face 
by  their  weight,  and  fit  the  face,  nose,  and  ears. 
Such  frames  do  not  cut  the  ears  or  groove  the  nose, 
whereas  light-weight  frames  have  no  rigidity,  cannot 
be  properly  shaped,  and  maintain  their  position  by 
pulling  from  the  nose  to  the  ears,  which  is  not  only 
annoying,  but  necessitates  constant  adjustment.  The 
ideal  frames  are  what  are  known  in  the  trade  as  798 ^ 
(rimless)  and  718}^  (rimmed)  14-karat  gold  spec- 
tacles. 

Fitting  of  Spectacles. — It  is  important  that  the 
bridge  or  nose-piece  should  be  in  accurate  apposi- 
tion to  the  nose,  but  not  deeply  indenting  it.  It  should 
be  round  on  cross  section,  rather  than  flat  or  triangu- 


THE    TEMPLE-PIECES. 


261 


lar  with  sharp  edges.      In  su1>scqueiit  adjuslnicnt  the 

original  fitting  of  the  bridge  shoukl  never  be  distnrbed. 

The  temple-pieces,  or  "  bows,"  shonhl  be  cnrved 

to  set  behind  the  ears  for  constant  wear,  bnt  may  be 


Fig.  64. — Spectacles  properly  adjusted. 

straight  when  the  spectacles  are  used  only  for  close 
work.     They  should  extend  in  a  direct  line  from  the 


/  V 

Fig.  65. — Improperly  fitted  spectacles 


hinges  on  the  outer  lens-attachment  to  the  top  of  the 
ears.  The  curve  at  the  top  of  the  ear  should  be  sharp, 
and  the  temple-pieces  should  conform  to  the  shape  of 


262 


THE  EYE. 


the  back  of  the  ear  (Fig.  64).  The  typical  careless 
fitting  is  shown  in  Fig.  65.  The  bows  should  be 
shaped  to  the  face  and  in  accurate  apposition,  but 
not  grooving  the  skin  of  the  temple,  thus  preventing 
movement  in  walking,  running,  etc. 

The  lenses  must  be  of  such  size  and  shape  that 
the  wearer  does  not  see  over  or  under  them,  and  they 


Fig.  66. — Properly  centered  lenses. 


must  be  properly  centered  and  be  at  equal  distance 
from  the  eyes  (Fig.  66).  Improper  centering  and  un- 
equal distance  from  the  eyes  (Fig.  6'])  often  produce 
prismatic  and  other  effects  so  injurious  as  to  offset 
any  optic  assistance  afforded  by  the  glasses,  and  par- 


FlG.  67. — Improperly  centered  lenses. 

ticularly  is  this  the  case  in  high-power  lenses.  Lenses 
should  be  ground  dull  on  the  edges.  Polished  edges 
not  only  cause  annoying  reflections,  but  are  much 
more  conspicuous. 

Position  of  Spectacles. — The  upper  edges  of  the 
lenses  should  be  slightly  inclined  forward,  as  most  of 


CARE    OF  SPECTACLES.  263 

tlie  time  the  eyes  are  directed  downward,  and  in  the 
inclined  position  the  axis  of  vision  will  strike  the 
surface  of  the  lens  at  a  right  angle,  and  so  avoid 
reflection.  In  glasses  for  near  work  only  the  inclina- 
tion may  be  made  greater. 

To  secure  the  proper  optic  assistance  from  lenses, 
they  should  be  worn  as  close  to  the  eyes  as  possible, 
and  in  cases  in  which  very  strong  lenses  are  worn 
any  interfering  eyelashes  may  be  trimmed  at  short 
intervals  without  noticeably  altering  their  growth  or 
texture. 

Concave  lenses  diminish  in  refractive  power  as  they 
are  moved  from  the  eye,  while  the  reverse  is  true  of 
convex  lenses.  This  explains  why  old  persons  who 
have  worn  the  same  pair  of  convex  lenses  for  reading 
during  many  years,  gradually  push  them  further  and 
further  away  from  the  eyes. 

Care  of  Spectacles. — In  taking  off  spectacles  both 
hands  should  be  used  in  such  a  way  that  the  temple- 
pieces  are  not  pulled  widely  apart,  or  otherwise 
strained  so  as  to  wrench,  bend,  or  loosen  the  attach- 
ments. Some  persons  simply  pull  their  spectacles 
over  the  ears  and  weaken  the  tension  and  destroy  the 
shape  of  the  bows.  In  putting  on  spectacles,  the 
lenses  should  not  be  crushed  against  the  eyelashes 
and  soiled.  The  bridge  should  be  placed  one-third 
down  the  nose,  grasping  the  temple-pieces  near  the 
ear-curve  between  the  thumb  and  first  two  fingers. 
The  ear-curve  should  then  be  bent  over  the  top  of  the 
ears  without  dragging  the  lenses  any  closer  to  the 
eyes;  the  frame  should  be  pushed  into  position,  and, 
lastly,  the  temple-pieces  should  be  pressed  down 
upon  the  tops  of  the  ears. 


264  THE  EYE. 

Spectacles  should  be  folded  as  little  as  possible,  to 
keep  the  hinges  and  attachments  stiff.  Instead  of 
putting  them  in  a  case  at  night  on  retiring,  they 
should  be  left  unfolded  and  resting  on  the  edges  of  the 
lenses  upon  a  shelf,  mantle,  bureau,  or  some  other 
article  of  furniture.  Lenses  should  never  be  laid  on 
their  face,  but  always  on  edge.  If  cleansed  with 
improper  material  or  placed  face  down  they  are  liable 
to  become  soiled  or  scratched.  Should  the  latter 
occur,  the  only  remedy  is  repolishing  or  renewal. 
Glasses  not  perfectly  clear  and  clean  not  only  inter- 
fere with  vision,  but  also  cause  unnecessary  strain 
and  irritation. 

Lenses  should  be  cleansed  several  times  daily.  For 
this  purpose  a  clean  unstarched  cotton  or  linen 
handkerchief  may  be  used.  Chamois,  leather,  tissue 
paper,  silk,  or  woollen  material,  etc.,  may  scratch  the 
surfaces.  To  remove  all  obscurities  (except  in  bifocal 
glasses)  the  lenses  may  be  cleansed  with  ammoniated 
water  once  or  twice  daily.  In  cleansing,  the  frame 
should  be  firmly  grasped  at  the  outer  edge,  close  up  to 
the  lens,  near  the  hinge,  with  the  thumb  and  forefinger 
of  the  left  hand,  and  not  by  the  bridge.  The  frame 
of  the  lens  being  cleaned,  and  not  the  opposite  one, 
should  be  held.  In  cleaning  rimless  eye-glasses, 
great  care  must  be  exercised  not  to  bend  or  change 
the  tension  of  the  spring. 

Reading-spectacles,  which  are  to  be  put  on  and 
taken  off  constantly,  are  sometimes  more  conveni- 
ently made  with  straight  temple-pieces,  particularly 
in  women,  on  account  of  the  abundance  of  hair  about 
the  temples.     Children  and  persons  engaged  in  occu- 


BIFOCAL   LENSES.  265 

pations  in  which  the  lenses  may  be  exposed  to  vio- 
lence should  wear  spectacles  with  rims. 

Eye-glasses,  or  "  pince-nez,"  may  be  used  by 
adults  when  the  lenses  are  not  too  heavy  or  when 
there  is  little  or  no  astigmatism,  provided  the  bridge 
and  sides  of  nose  are  adapted  for  them.  The  new 
highly-tempered  and  thin  spring,  and  the  modern 
nose-piece  or  guards  with  adjustable  arms  or  offsets 
permit  many  more  persons  to  be  accurately  fitted  in 
eye-glasses  than  previously.  But  even  when  properly 
fitted,  eye-glasses  may  not  be  put  on  in  the  same  posi- 
tion or  place  twice  in  succession,  and  they  are  easily 
bent,  losing  their  exact  position  before  the  eye,  which 
by  changing  the  axis  of  a  cylindric  lens,  particularly 
in  high  astigmatism,  may  greatly  lessen  the  optical 
improvement.  The  oculist  inay  have  fitted  the 
glasses  accurately  after  the  most  careful  tests,  and  yet 
have  his  results  unsatisfactory  on  account  of  the  fool- 
ish pride  of  a  patient  who  insists  on  wearing  eye- 
glaSvSes  when  spectacles  alone  will  give  relief  Eye- 
glasses are  more  conveniently  carried  about,  and  need 
not  be  folded  in  a  case  and  may  be  hung  on  a  hook  on 
the  vest  or  waist.  They  may  have  rims  or  not,  ac- 
cording to  the  liability  to  breakage  or  to  the  taste  of 
the  wearer. 

Bifocal  Lenses. — Persons  past  middle  life  with 
defective  eyes  require  a  separate  pair  of  glasses  both 
for  reading  and  for  distance.  The  readiuQ;  lenses 
cause  a  blurring  of  vision  at  a  distance,  while  the 
distance  lenses  are  insuflScient  for  reading,  and  the 
greater  the  age  the  greater  is  the  difference  between 
the  lenses  for  far  and  near  vision.  In  such  cases,  in- 
stead of  two  pairs  of  glasses  to  be  changed  according 


266 


THE   EYE. 


to  the  visual  needs,  bifocal  lenses  may  be  used  (Fig. 
68).  The  improved  form,  with  a  reduced  additional 
convex  segment,  cemented  on  the  distance  lens,  is  far 
more  satisfactory  than  the  old  split  Franklin  bifocals. 
The  lower  segment  should  be  about  seven-eighths  of 
an  inch  wide  and  one-half  inch  high;  the  upper  edge 
more  curved  than  the  lower.  If  the  occupation  of 
the  patient  subjects  him  to  high  degrees  of  heat  or 
steam,  the  lower  segment  should  be  inserted  into  a 


Distance 


Reading 


Fig.  68. — Bifocal  lens. 

groove  in  the  bottom  of  the  distance  lens  and  placed 
in  rimmed  spectacles  or  eye-glasses  instead  of  being 
cemented  on  with  Canada  balsam.  The  two  lenses 
may  also  be  ground  on  one  piece  of  glass  ;  but  this 
form  of  bifocals  is  more  expensive. 

There  is  much  foolish  prejudice  against  wearing 
bifocal  lenses.  Although  it  requires  some  little  time 
to  become  accustomed  to  them,  bifocal  glasses 
ultimately  give  far  greater  satisfaction,  and  are  more 
convenient  than  two  different  pairs  of  glasses.  The 
patients  must  be  warned  about  the  danger  of  making  a 
mistake  in  going  up  or  down  the  stairs,  getting  on 
and  off  cars,  etc.,  until  they  have  become  accus- 
tomed to  the  prismatic  displacement  occasioned. 

Bifocal  lenses  need  the  greatest  care  to  keep  them 


PANTOSCOPIC  SPECTACLES.  267 

from  getting  out  of  adjustnicut.  More  than  others 
they  demand  absohite  precision  of  position.  Any 
imperfection  in  the  cementing  of  bifocal  segments 
should  be  remedied  at  once.  The  Canada  balsam 
used  is  sometimes  disturbed  by  the  heat  and  moisture 
of  the  face,  and  becomes  opalescent,  interfering  with 
vision.  If  this  occurs,  the  lenses  should  at  once  be 
returned  to  the  optician  for  repairing. 

Trifocals  have  been  used  by  bookkeepers,  musi- 
cians, and  other  persons  who  are  compelled  to  use 
their  eyes  alternately  at  the  reading  distance  and  at  a 
distance  just  beyond,  as  in  copying,  reading  music, 
etc.  Such  lenses  must  be  too  large  to  be  comfortable, 
and  then  are  unsatisfactory.  It  is  better  to  have  a 
separate  pair  of  bookkeepers'  or  musicians'  glasses 
adapted  to  a  focus  of  from  twenty  to  twenty-five 
inches. 

Pantoscopic  spectacles  is  the  name  sometimes 
given  to  those  in  which  only  one-half  of  a  lens  is 
used,  allowing  the  wearer  to  look  over  them  at  dis- 
tant objects.  They  are  convenient  for  persons  who 
need  only  a  reading-glass,  or  they  may  be  employed 
as  hook  fronts  over  distance  lenses  (Fig.  69). 


Fig.  69. — Half-hook  fronts  for  reading. 

After  cataract-extraction  or  for  persons  with  one  eye 
reversible  frames  may  be  used,  the  lens  in  one  side 
being  used  for  distance  vision,  while  that  on  the  other 
is  employed  in  reading.  However,  a  bifocal  lens  is 
preferable  in  such  cases. 


268  THE  EYE. 

Lorgnettes  (lorgnons)  and  monocles  may  be  used 
occasionally,  but  should  not  be  employed  constantly  as 
substitutes  for  spectacles  or  eye-glasses.  The  same 
optic  correction  necessary  in  the  distance  spectacles 
or  eye-glasses  must  be  used  in  the  lorgnette,  and  the 
lenses  should  only  be  fitted  by  an  oculist.  There  is 
a  foolish  idea  that  a  telescopic  or  magnifying  lens 
producing  an  effect  somewhat  like  opera-glasses  may 
be  inserted  in  a  lorgnette.  Such  optic  aid  cannot  be 
obtained  without  a  dioptric  system  of  at  least  two 
lenses.  Although  persons  with  nearly  normal  vision 
may  think  at  first  glance  that  they  see  better  with  a 
low-power  concave  lens,  the  use  of  such  correction 
when  not  indicated  by  myopia  causes  extra  eye-strain. 
A  person  with  perfect  eyes  will  derive  no  advantage 
at  distance  with  a  lens  in  lorgnettes,  and  persons  with 
faulty  vision  cannot  be  made  to  see  better  with  lorg- 
nette lenses  than  with  their  proper  correction  worn 
in  spectacles  or  eye-glasses. 

Lorgnettes  are  also  used  by  elderly  women  for 
carrying  reading-glasses,  and  bifocal  glasses  are  also 
used  in  this  manner  on  the  street,  in  church,  at  the 
opera,  etc.  If  the  patient  has  very  much  astigmatism 
or  needs  a  high-power  lens,  the  lorgnettes  must  be 
carefully  fitted  and  the  lenses  accurately  centered, 
and  they  should  always  be  held  exactly  before  the 
center  of  the  pupils  and  in  a  straight  position. 

Tinted  glasses  should  seldom  be  ordered  for  con- 
stant use,  but  may  be  temporarily  prescribed  in  in- 
flammatory conditions,  during  mydriasis,  for  use  at  the 
seashore,  etc.  The  habit  of  wearing  tinted  glasses 
is  difficult  to  overcome.  Persistent  dread  of  light 
(photophobia)  is  usually  due  to  uncorrected  or  im- 


THE    PRFJLIDICE   AG.UNST   WEARING    CLASSES.    269 

jM^operly  corrected  ametropia.  Tt  is  a  well-known  fact 
that  the  constant  nse  of  tinted  glasses  is  most 
employed  in  conntries  where  the  importance  of  cor- 
recting eye-strain  even  in  comparatively  low  defects 
is  not  recognized.  When  tinted  glasses  are  in- 
dicated, Ivondon-smoke  plane  lenses  should  be  used, 
and  if  necessary  worn  over  the  ordinary  spectacles  or 
eye-glasses  and  taken  off  indoors,  rather  than  to  have 
the  correction  ground  in  smoked  glasses.  Coquilles 
should  be  avoided,  as  they  generally  have  some 
spheric  or  cylindric  effect  on  an  irregular  surface. 
Blue,  green,  or  any  other  colored  glasses  should 
never  be  used  when  plain  smoked  glasses  are  obtain- 
able. 

Before  leaving  the  oculist's  care  the  patient  should 
return  with  the  glasses  for  examination  of  the  adjust- 
ment and  verification  of  the  lenses  by  neutralization. 
Both  spectacles  and  eye-glasses  may  feel  uncomfort- 
able for  the  first  few  days.  Tender  skin  may  be  bathed 
with  witch-hazel,  and  hardened  by  applications  of 
alcohol,  cologne-water,  alum-water,  etc.  Frequent 
visits  to  the  optician  for  readjustment  are  necessary, 
and  for  this  service  the  best  opticians  make  no  charge 
to  their  regular  customers.  Glasses  should  never  be 
worn  when  decentered  or  otherwise  out  of  shape. 
The  good  effects  of  many  careful  examinations  of  re- 
fraction have  been  spoiled  by  maladjusted  and  decen- 
tered lenses. 

The  prejudice  against  wearing  glasses  is  happily 
diminishing  and  disappearing  in  most  American  com- 
munities. Carefully  prescribed  and  correctly  adjusted 
lenses  constitute  one  of  the  greatest  boons  to  human- 
ity, and  when  they  are  needed  nothing  else  will  take 


2/0  THE    EYE. 

their  place.  Headaches  and  other  asthenopic  symp- 
toms will  continue  until  the  necessary  optic  correc- 
tion is  worn.  It  is  not  uncommon  to  see  people,  who 
have  been  advised  of  the  necessity  of  wearing  glasses, 
dose  themselves  with  headache-powders,  antibilious 
pills,  nerve-tonics,  etc.  ad  nauseam^  rather  than  accept 
the  proper  means  of  relief.  Generally  this  is  due  to 
vanity  of  personal  appearance  ;  but  occasionally  it 
arises  from  the  belief  that  oculists  invariably 
put  glasses  on  all  their  patients,  or  that  if  one 
starts  to  wear  glasses  the  eyes  will  be  so  weakened 
that  he  will  never  be  able  to  leave  off  wearing 
them. 

Explanation  of  the  frequency  with  which  glasses 
are  worn  in  the  present  day  is  often  asked  of  physi- 
cians and  oculists.  The  chief  reason  is  doubtless  the 
excessive  demand  of  modern  life  on  the  eyes. 
Schools,  newspapers,  magazines,  books,  and  free 
libraries  have  greatly  multiplied  in  the  last  few 
decades.  Artificial  illumination  has  been  so  perfected 
that  every  encouragement  is  offered  for  reading,  sew- 
ing, and  other  near  work  at  night.  Another  reason 
is  that  formerly  the  importance  of  eye-strain  in  caus- 
ing inflamed  lids,  habitual  headache,  and  other 
more  remote  reflexes  was  not  recognized.  Then  the 
advice  of  an  oculist  was  sought  only  when  vision  was 
defective,  while  to-day  a  large  number  of  an  oculist's 
patients  are  slightly  far-sighted  or  astigmatic  and  have 
excellent  vision,  but  complain  of  reflex  asthenopic 
symptoms,  the  most  common  of  which  is  headache. 
Again,  much  of  the  modern  science  of  ophthalmology 
and  the  refinements  in  the  grinding  of  lenses  and 
fitting  of  spectacles  and  eye-glasses  by  opticians  are 


INITIAL   DISCO  MI  OR  T   WITH  GLASSES.  zjl 

of  very  recent  clevelopiiieut.  The  final  reason,  and 
not  the  least  important,  is  that  an  ancient  senseless 
prejudice  has  been  permanently  overcome.  When 
glasses  are  indicated  they  are  almost  as  necessary  as 
proper  rest,  and  the  longer  they  are  withheld  the 
more  serious  will  be  the  consequence.  As  to  the 
frequent  inability  to  discontinue  their  use  later,  if 
this  is  the  case,  no  better  proof  of  the  wisdom  of  pre- 
scribing them  can  be  oflfered.  On  the  other  hand,  it 
not  infrequently  happens  that  by  tiding  over  a  threat- 
ened nervous  breakdown  during  a  temporary  state  of 
ill-health,  the  use  of  glasses  allows  the  system  to 
recuperate  to  such  a  point  that  they  may  then  be 
discarded,  when  otherwise  either  the  health  might 
have  been  irreparably  ruined  or  the  ultimate  resort  to 
glasses  become  permanent. 

The  proper  glasses  do  not  always  suit  at  first, 
and  the  oculist  is  often  called  upon  for  an  explana- 
tion. In  far-sightedness  and  astigmatism  the  accom- 
modation is  so  hypertropliied  and  cramped  by  long 
years  of  strain  that  the  full  correction  found  under 
mydriasis  is  rejected  when  the  effects  of  the  drops 
pass  off.  In  such  cases  the  proper  lenses  may  blur 
distant  vision,  and  the  patient  may  even  see  much 
better  at  a  distance  without  them.  However,  the 
glasses  should  be  persisted  with,  in  the  same  manner 
that  a  disagreeable  medical  treatment  is  pursued, 
until  the  accommodation  relaxes,  when  all  the  objec- 
tions disappear  and  the  asthenopic  symptoms  are 
relieved. 

If  patients  succumb  to  their  early  difficulties  with 
glasses  and  only  wear  them  spasmodically,  the  initial 
discomfort  is  only  prolonged.     If  the  glasses  become 


272  TJflE  EYE. 

absolutely  unbearable,  the  oculist's  advice  should  be 
sought  before  they  are  discarded.  The  spasm  of 
accommodation  is  only  one  of  many  reasons  for  the 
discomfort  of  new  lenses.  Often  the  apparent  change 
in  the  size  of  objects  and  the  false  estimation  of  dis- 
tance are  sources  of  perplexity;  but  these  also  dis- 
appear in  a  few  days.  In  such  cases  it  is  common 
to  hear  such  complaints  as  "the  glasses  make  me 
dizzy, "  "  everything  seems  crooked, "  "  the  floor 
seems  too  close  to  me,"  "the  glasses  make  me  ner- 
vous," etc. 

The  reflections  from  the  glass  and  the  irritation  by 
contact  with  the  skin  are  other  troubles  which  soon 
disappear.  Again,  persons  who  have  never  worn 
glasses  will  turn  their  eyes  instead  of  slightly  turn- 
ing their  heads  when  looking  sideways  and  so  bring 
about  confusion  of  vision.  Some  patients,  during 
their  early  period  of  annoyance,  happening  to  pick 
up  a  pair  of  weaker  convex  or  stronger  concave 
glasses,  as  the  case  may  be,  belonging  to  an  acquaint- 
ance, and,  finding  that  for  the  moment  vision  appears 
plainer,  may  foolishly  believe  that  their  oculist  has 
given  them  the  wrong  optic  correction.  It  is  by 
reason  of  this  same  false  momentary  judgment  in 
trying  lenses  without  the  use  of  mydriatics  that 
patients  who  select  glasses  in  an  optician's  store 
are  so  often  given  a  wrong  correction. 

Finally,  certain  near-sighted  adults  who  have 
never  worn  a  distant  correction,  although  acknowl- 
edging the  visual  improvement  afforded  by  the  proper 
glasses,  yet  have  become  so  contented  with  the  gen- 
eral haze  before  their  eyes,  and  are  able  to  read  so 
easily  with  their  naked  eyes,  that  they  refuse  to  use 


AirnricfAr.  eves.  273 

glasses  constantly,  although  employing  lorgnettes 
and  eye-glasses  occasionally  at  the  theatre,  etc. 
Such  persons  should  be  informed  of  the  danger  of  pro- 
gressive myopia  when  the  proper  lenses  are  not  worn, 
particularl)'  in  prolonged  close  work  (see  page  214). 

Glasses  should  be  changed  at  frequent  inter- 
vals, particularly  for  children  or  adults  who  are  rapidly 
changing  in  stature.  A  great  difference  in  refraction 
may  occur  after  profound  shock,  protracted  illness, 
confinement,  and  other  similar  depressing  conditions. 
A  good  rule  to  follow  is  to  seek  the  advice  of  an  ocu- 
list whenever  any  of  the  original  asthenopic  symp- 
toms recur  or  when  there  is  disturbance  of  either  far 
or  near  vision;  and  in  the  absence  of  any  subjective 
indications  of  change,  it  is  not  an  unwise  procedure 
to  consult  an  oculist  at  least  every  three  years,  and  so 
forestall  any  disagreeable  symptoms.  The  necessity  of 
changing  glasses  to  correct  the  constantly  changing 
refraction  is  not  generally  known,  and  it  is  not  un- 
common to  find  educated  persons  wearing  one  pair 
of  glasses  for  many  years,  and  often  aged  persons  use 
the  same  reading-glasses  over  long  periods,  gradually 
pushing  them  down  the  nose  as  the  presbyopia 
increases. 

Artificial  Eyes. — In  persons  so  unfortunate  as  to 
lose  an  eye  or  who  have  had  enucleation  performed 
on  account  of  disfigurement,  an  artificial  eye  offers 
a  good  substitute  and  is  often  a  decided  cosmetic 
advantage.  Artificial  eyes  are  made  of  every  size 
and  variety.  The  requisites  in  selection  are  the 
proper  color  of  the  whitish-blue  sclera,  which  differs 
in  shade  from  that  in  the  pale  blonde  to  the  dark  bru- 
nette, the  color  of  the  iris,  and  the  normal  size  of  the 


274  THE  EYE. 

pupil.  Artificial  eyes  are  generally  made  of  porcelain 
and  are  mere  shells,  although  recently  hollow  glass  and 
metal  bulbs  have  been  used  to  fill  out  the  orbit.  The 
amount  of  tissue  and  muscle  left  in  an  orbit  after 
enucleation  of  an  eyeball  determines  the  motility  of 
the  stump.  In  some  orbits  there  is  such  free  move- 
ment of  the  stump  over  which  the  shell  fits  that  it 
follows  exactly  the  ordinary  movements  of  the  sound 
eye  and  is  only  discoverable  in  positions  of  extreme 
rotation.  This  is  particularly  the  case  when  abscission, 
evisceration,  implantation,  or  Mules' s  operation  has 
been  practised. 

An  artificial  eye  may  be  first  worn  after  a  lapse  of 
two  or  three  weeks  from  the  date  of  operation  if  all 
inflammation  has  subsided.  Early  application  of  an 
artificial  eye  is  advisable  to  prevent  absorption  of 
orbital  fat.  The  orbit  is  very  tolerant  of  foreign 
bodies.  However,  to  accustom  the  tissues  thoroughly 
to  an  artificial  eye,  it  should  not  be  worn  more  than  a 
few  hours  at  a  time  for  the  first  few  days. 

To  insert  an  artificial  eye,  it  is  lubricated  and  the 
broad  outer  end  slipped  under  the  upper  lid,  which 
is  slightly  raised;  the  lower  lid  is  then  drawn  down- 
ward and  the  patient  is  told  to  look  down,  when  the 
eye  is  gently  manipulated  into  place.  Irritation  of 
the  stump  by  an  artificial  eye  has  led  to  sympathetic 
involvement  of  its  fellow,  and  must  be  guarded 
against.  An  artificial  eye  should  be  taken  out  at 
night  and  washed,  and  placed  where  it  will  not  un- 
dergo a  marked  change  of  temperature.  It  must  be 
replaced  every  two  or  three  years,  as  it  loses  its  luster 
and  becomes  noticeably  difierent  from  the  sound 
orgfan. 


HYGIENE   OF  THE   BRAIN    AND   NERVOUS 
SYSTEM, 

By  J.   W.   COURTNEY,  M.  D., 

OF    BOSTON, 
Physician  for  Diseases  of  the  Nervous  vSystem,  Boston  City  Hospital. 


GENERAL  PRINCIPLES. 

Nervous  tissue  is  one  of  the  most  delicate  and 
highly  organized  in  the  body,  and  possesses  the  least 
reparative  power.  On  this  account  Nature  has  pro- 
vided it,  for  the  most  part,  with  appropriate  bony 
protection — the  cranium  in  the  case  of  the  brain, 
and  the  spinal  column  in  that  of  the  cord — against 
external  violence.  For  the  nerves  which  enter  and 
leave  the  brain  and  cord  through  apertures  in  their 
bony  coverings  she  has,  however,  generally  speak- 
ing, made  no  such  wise  provision,  but  has  endeavored 
to  compensate  for  her  shortcoming  by  endowing  them 
with  a  much  greater  power  for  repair  than  either  the 
brain  or  cord. 

The  general  construction  and  mechanism  of 
the  central  nervous  system  with  its  peripheral  ap- 
pendages, the  nerves,  are  analogous  in  all  essential 
details  to  a  great  telegraphic  system.  By  the 
nerves,  which  ramify  in  all  directions  like  a  lot  of 
telegraph  wires,  the  most  distant  parts  of  the  body 
are  brought  into  communication  first  with  the  spinal 
cord  and  then,  if  need  be,  with  the  central  terminal 

275 


276  THE   BRAIN  AND   NERVOUS  SYSTEM. 

station,  the  brain,  where  certain  messages  are  re- 
ceived and  interpreted  by  our  consciousness,  and 
others  sent  down  through  the  appropriate  nerves 
lying  in  the  great  cables  (so  to  speak)  of  the  brain 
and  cord,  to  be  switched  off  at  the  proper  levels  to 
their  destinations. 

When  we  consider  that  it  is  upon  the  perfect 
integrity  of  the  fine  adjustment  of  this  delicate  and 
intricate  organization  that  the  healthy  functional 
activity  of  every  other  tissue  in  the  body,  even  to 
that  of  the  most  insignificant  _  secreting  gland,  de- 
pends, we  are  in  a  position  to  estimate  the  extent  to 
which  our  physical  as  well  as  mental  well-being  is 
under  its  control.  To  increase  the  marvel  we  have 
only  to  learn  that  Nature  has  seen  fit  to  make  what 
have  been  termed  the  master  tissues  of  the  body,  the 
brain  and  spinal  cord,  dependent  for  their  own 
vitality  upon  a  blood-supply  which  comes  to  them 
through  arteries  which,  for  the  most  part,  are  what 
are  called  end-arteries,  or  arteries  which  have  no 
communication  with  one  another;  a  plan  which 
means  almost  inevitable  death  to  these  parts  when 
the  arteries  break  down  or  become  occluded. 

With  this  brief  statement  of  the  paramount  im- 
portance of  the  role  played  by  the  brain  and  nervous 
system  in  the  carrying  on  of  vital  functions,  we  are 
in  a  better  position  to  enter  upon  a  consideration  of 
the  measures  which  may  be  adapted  for  the  main- 
tenance of  these  organs  in  a  healthy  state. 

Influences  of  Heredity,  Education,  and  Environ- 
ment.— At  the  present  day  we  frequently  hear  the 
term  "born  degenerate"  used  to  designate  some 
unfortunate  who  happens   to   be   the   possessor  of  a 


HEREDITY  AND    ENVJRONMEN'I'.  2'J'J 

liigli-arclied  palate,  iiiissliapeii  cars,  or  an  asyminctric 
skull,  and  who,  under  stress  of  circumstances,  be- 
trays some  mental  or  moral  obliquity.  The  argument 
is  that  Nature  while  inflicting  upon  this  individual 
outward  stigmata  of  her  freakish ness,  has  been 
equally  unkind  in  the  matter  of  moral  and  intellec- 
tual endowments,  and  that  he,  in  sinning  against 
well-recognized  laws,  is  simply  the  victim  of  his  own 
vicious  organism.  To  argue  thus  is  fallacious  in  the 
extreme,  for  it  throws  a  most  unwarrantable  burden 
upon  Nature,  and  leaves  absolutely  nothing  to  the  ac- 
count of  two  factors  which  are  of  vast  importance  in 
determining  the  mental,  moral,  and  social  status  of 
every  individual — namely,  education  and  environ- 
ment. In  proof  of  this,  one  has  only  to  seek  in  the 
circle  of  his  own  acquaintances.  This  all  leads, 
however,  to  the  matter  of  heredity  and  its  influence 
upon  a  person's  nervous  and  mental  welfare.  Upon 
this  point  may  be  quoted  the  following  admirable 
statement  of  the  facts  in  the  case  by  Dr.  James  J.  Put- 
nam:^ "  Fortunately  for  the  educational  outlook,  the 
evidence  has  begun  to  accumulate  that  a  morbid  in- 
heritance is  not  the  inevitably  crushing  and  baneful 
thing  that  it  has  been  thought.  "  We  come  into  the 
world,  each  one  a  being  of  limited  capacity,  but  in 
other  respects  free  to  become  what  circumstances 
make  us,  and  responsible,  to  the  extent  of  our  capac- 
ity, for  our  lot.  We  bring  no  ticket-of-leave  which 
stamps  us  as  drunkards  or  maniacs  on  probation,  but 
we  do  bear,  in  the  histories  of  our  ancestors,  a  certifi- 
cate that  hints  by  what  efforts  and  by  what  avoid- 

'  The  Shattuck  lecture — "Not  tlie    Disease  only,  but  also  the  Man." 
By  James  J.  Putnam,  M.  D.,  of  Boston. 


278  THE  BRAIN  AND  NERVOUS  SYSTEM. 

ances  we  can  make  ourselves  reasonable  successes  in 
our  respective  lines.  There  is  no  original  sin,  and 
not  even,  as  it  seems  to  me,  original  propensity,  but 
only  original  capacity  and  original  limitation,  and 
even  limitation  is  only  another  name  for  latent  ca- 
pacity. " 

Anyone  at  all  familiar  with  nervous  and  mental 
diseases  must  at  once  be  struck  with  the  unquestion- 
able soundness  and  fairness  of  Prof,  f'utnam's  point 
of  view.  It  brings  the  question  of  personal  equation 
and  responsibility  into  its  proper  focus  and  hints  at 
the  happy  results  which  we  may  confidently  expect 
from  a  due  regard  for  the  laws  of  hygiene  in  its 
broadest  sense.  Certainly  it  presents  a  most  striking 
and  stimulating  contrast  to  the  pessimistic  fatalism  of 
the  views  previously  alluded  to. 

With  regard  to  the  brain  and  nervous  system  the 
hygienic  problem  is  a  far-reaching  one,  and  if  we 
would  attack  it  at  its  very  source,  we  must  ask  our- 
selves at  the  outset  by  what  efforts  and  avoidances  we 
may  expect  to  ensure  the  unborn  child  against  the 
dangers  which  threaten  the  stability  of  its  mental 
and  nervous  organization.  This  is  a  question  which 
leads  us  directly  back  to  the  period  antedating  con- 
ception. In  many  unfortunate  cases  at  this  time  the 
personality  of  one  or  both  parents  is,  on  account  of 
alcoholism  or  other  vice,  for  the  time  being,  in  a 
condition  of  morbid  alteration,  the  deleterious  influ- 
ence of  which  may  be  profound  and  enduring.  But 
proper  care  of  the  mind  and  body  at  this  time  is  only 
the  beginning  of  parental  responsibility.  From  the 
commencement  of  pregnancy  to  its  close,  and  all 
through  the  period  of  lactation,  every  effort  should  be 


ADVENT  OF   THE   SCHOOI.-COING   AGE.  279 

made  to  divert  from  the  mother  all  possible  causes 
of  nervous  wear  and  tear,  chief  and  foremost  of  which 
are  worry  and  anxiety. 

The  nervous  and  mental  hygiene  of  childhood 
antedating  the  school-going  epoch  is  comprised  in 
such  elementary  factors  as  proper  food  and  clothing, 
an  abundance  of  sleep,  and  life  in  the  open  air. 

The  advent  of  the  school-going  age  presents 
many  serious  problems,  and  as  it  is  often  at  this  time 
that  the  laws  of  mental  and  nervous  hygiene  suffer 
the  first  infringement  by  which  profoundly  deleterious 
results  are  brought  about,  the  whole  subject  is  deserv- 
ing of  treatment  at  some  length. 

It  is  contended  by  certain  authorities  that  Ameri- 
can children  are  sent  to  school  at  too  early  an  age  and 
compelled  to  do  an  amount  of  mental  labor  incompat- 
ible with  the  healthy  growth  of  their  physical  organi- 
zation. With  regard  to  this  it  may  be  stated  dogmat- 
ically at  the  outset  that,  so  far  as  children  under  twelve 
years  of  age  are  concerned,  the  danger  of  brain  over- 
work has  been  unjustly  exalted,  for,  with  very  few 
exceptions,  their  natural  inattention  and  playfulness 
are  their  safeguard.  Of  far  greater,  in  fact,  of  para- 
mount importance,  as  far  as  nervous  and  mental 
welfare  is  concerned,  is  the  matter  of  sunlight  and 
pure  air  in  the  school-room,  and  of  seats  and  desks 
which  will  not  distort  the  pliant  spines  and  chest- 
walls  of  such  children,  thereby  impeding  the  circula- 
tion to  the  important  nervous  centers  upon  which  the 
strain  of  study  naturally  comes.  It  is  toward  matters 
such  as  these  that  parents  and  educators  should  be  led 
to  turn  their  serious  attention,  for  wnth  such  crying 
necessities  unattended  to,  the  present  w^arfare  which  is 


28o  THE   BRAIN  AND   NERVOUS  SYSTEM. 

waging  in  educational  circles  over  the  teaching  of 
matters  of  tenth-rate  importance,  notably  the  food- 
value  of  alcohol,  is  superlatively  premature,  to  say  the 
least.  Impure  air  we  know  not  to  be  a  food  but  a 
poison,  and  a  distorted  spine  in  a  growing  child  is 
more  easily  acquired  than  corrected. 

In  regard  to  the  class  of  children  that  form  the  ex- 
ception to  the  general  rule,  a  word  of  precaution  is 
demanded.  Such  children  come  under  the  head  of 
what  may  be  termed  the  dangerously  precocious,  and 
for  them  the  modern  overstimulating  methods  of 
school-instruction  are  fraught  with  dangers  not  easily 
overestimated.  As  a  rule  they  are  frail  in  body  and 
of  a  decidedly  tubercular  taint,  the  activity  of  their 
physical  powers  seeming  to  be  in  the  inverse  ratio  to 
that  of  their  mental.  What  such  children  really  need 
is  a  repression  rather  than  a  stimulation  of  their  men- 
tal faculties.  For  them  the  ideal  training  is  one  of 
their  muscles  and  of  their  vegetative  functions,  and 
this  they  can  get  only  by  the  freest  possible  life  out 
of  doors. 

After  the  age  of  twelve  the  question  of  brain  over- 
work really  begins  to  assume  proportions  worthy  of 
serious  consideration,  for  it  is  then  that  what  we  may 
term  the  fancy-work  of  education  commences.  By 
this  is  meant  that  children  are  launched  upon  the 
variegated  curricula  of  the  high-school  and  academy, 
and  are  subjected  to  a  process  of  mental  gymnastics 
sufficiently  arduous  to  strain  the  powers  of  an  adult, 
to  say  nothing  of  children  who  are  approaching  that 
very  important  physical  crisis,  puberty. 

Puberty  and  its  attendant  dangers  to  mental  and 
nervous  health  have  caused  the  expression  of  many 


PUBERIY  AN  J)   ITS  ATTPIA'DANJ'  DANCI-.h'S.     2H  I 

extreme  views.  There  is  no  question  that  in  both 
sexes  (but  especially  in  boys)  the  psychical  effect  of 
puberty  often  outweighs  the  physical  ;  hence  we 
begin  to  observe  the  real  awakening  of  the  "ego," 
of  the  condition  of  self-consciousness,  the  proper 
trend  of  which  means  so  much  for  the  health  of  the 
nervous  system.  It  is  a  period  certainly  when 
nervous  and  mental  aberrations  are  not  uncommon, 
but  are  we  right  in  attributing  them  all,  as  certain 
authorities  are  inclined  to  do,  to  brain  over-work  ? 
Such  a  contention  seems  wholly  unjustified  except 
in  rare  instances.  The  root  of  the  evil  lies  largely 
in  the  mawkish  sentimentality  and  artificial  modesty 
which  possess  a  large  percentage  of  parents  through- 
out the  land,  and  prevent  them  from  explaining  to 
their  children  the  mental  as  well  as  physical  sig- 
nificance of  the  changes  which  the  latter  are  destined 
to  undergo  at  this  period.  The  result  is,  in  the  case 
of  the  girl,  that  the  establishment  of  the  menses 
often  comes  as  a  mental  shock  which  may  prove 
the  last  straw  in  the  genesis  of  a  nervous  break- 
down, for  which  her  "studies"  have  already  paved 
the  way.  In  the  boy  the  reaction  is  different  and  fre- 
quently far  more  disastrous,  for  he,  finding  himself  in 
the  possession  of  a  newly-awakened  instinct,  is  often 
led  into  habits  which  may  mean  little  less  than  abso- 
lute mental  and  nervous  ruin. 

This  subject  is  well  worthy  of  the  serious  attention 
of  every  parent  and  teacher.  Much  ill-considered 
treatment  of  the  problem  has  found  its  way  into  text- 
books of  medicine  and  medical  waitings  in  general. 
This,  it  seems,  arises  from  an  undue  exaltation  of 
the  importance  of  the  direct  physical  results.      Such 


282  THE  BRAIN  AND  NERVOUS  SYSTEM. 

teaching  is  dangerous,  for  the  naturally  self-conscious 
youth  is  imbued  by  it  with  the  fear  of  irreparable 
bodily  injury,  self-inflicted.  A  vicious  cycle  is  estab- 
lished. He  quickly  becomes  self-analytical,  and  by 
autosuggestion  succeeds  in  bringing  about  actual 
physical  suffering.  The  primary  factor  of  moment 
is,  however,  the  implantation  of  the  morbid  fear,  and 
unless  this  is  quickly  eradicated,  the  complete  nerv- 
ous undoing  of  its  victim  is  in  time  effected  by  mis- 
guided medical  or  lay  advisors,  or  by  the  criminal 
insinuations  of  designing  quacks,  whose  villainous 
publications  are  constantly  flooding  the  country. 
The  teaching  of  practical  morality  is  the  key  to  the 
problem.  The  responsibility  of  the  entire  matter 
rests  primarily  with  parents  and  teachers;  but  to 
judge  from  the  prosperity  of  the  very  lowest  and 
most  offensive  sort  of  charlatans,  and  from  the  large 
number  of  persons  who,  under  the  scourge  of  the  most 
pitiable  mental  anguish,  seek  the  advice  of  reputable 
physicians,  it  would  seem  that  this  responsibility, 
great  and  significant  as  it  is,  rests,  in  many  instances, 
with  appalling  lightness. 

NEURASTHENIA  (Nervous   Prostration). 

General  Remarks. — In  that  limited  number  of 
cases  in  the  class  of  children  in  which  brain  over- 
work can,  with  a  reasonable  degree  of  accuracy,  be 
looked  upon  as  the  exciting  cause  of  nervous  break- 
down, it  may  be  said  of  them  that  they  are  usually  the 
victims  of  inherent  weaknesses  coupled  with  a  total 
disregard  of  the  most  elementary  rules  of  personal 
hygiene;  and  the  same  statement  is  applicable  to  col- 
lege  men   and  women.      The  condition  of  nervous 


NEUKASTJJKNIA.  283 

breakdown  thus  broii<^lit  about  dificrs  in  no  important 
characteristics  from  that  which  arises  from  other 
causes,  and  as  we  commonly  hear  it  spoken  of  as 
American  "nervousness"  or  "neurasthenia,"  it  will 
be  well  to  consider  all  the  factors  which  may  be 
active  in  its  production. 

To  speak  of  neurasthenia  as  a  condition  to  which 
the  American  people  are  inherently  liable  is  to  neg- 
lect the  facts  of  statistical  evidence.  The  average 
American  has  no  more  inherent  liability  to  suffer  from 
undue  exhaustion  of  his  nervous  powers  than  the 
representative  of  any  other  nation  on  earth.  And 
yet,  through  disregard  for  the  ordinary  laws  of  h)'- 
giene,  so  many  victims  are  added  yearly  to  the  num- 
ber who  fall  under  the  evil  consequences  of  an  outraged 
nervous  system,  that  the  question  of  prevention  be- 
comes one  of  vital  importance.  To  present  this  side 
of  the  subject  in  its  proper  light  a  preliminary  study 
of  the  causes  and  results  of  nervous  weakness,  or 
asthenia,  will  be  necessary. 

Definition. — The  term  "neurasthenia"  may  be 
said  to  denote  a  condition  of  pathologic  fatigue  of 
the  entire  nervous  system  and  also  to  connote  a 
coexistent  condition  of  morbid  nervous  irritability. 
Of  its  underlying  pathology  little  is  definitely  known 
so  far  as  the  human  subject  is  concerned,  but  from  the 
experimental  work  of  Hodge  ^  and  others  on  animals, 
to  which  reference  will  be  made  later,  it  would  seem 
that  we  are  not  altogether  justified  in  speaking  of 
it  as  a  condition  without  any  discoverable  pathologic 
basis. 

Causation. — The  subject  of  the  causation  of  this 

^  Hodge,  Journal  of  I\Iorphology,  Boston,  1892. 


284  THE   BRAIN  AND  NERVOUS  SYSTEM. 

condition  is  one  of  the  deepest  and  most  subtle  with 
which  the  physician  has  to  deal,  embracing  as  it 
does  a  consideration  of  factors  that  concern  not  only 
the  hereditary  aspect  of  the  individual,  but  also  the  edu- 
cational, the  latter  term  being  used  in  its  very  broadest 
sense.  These  two  factors,  heredity  and  education, 
are  the  most  important  elements  among  what  we  may 
term  the  predisposing  agents  in  the  genesis  of  the 
morbid  state  under  consideration.  As  a  strong  third 
comes  occupation.  The  prolific  inventor,  the  broker 
on  the  stock  exchange,  and  others  whose  business 
affairs  entail  perennial  emotional  unrest,  are  found  in 
the  majority  in  the  now  great  army  of  neurasthenics. 
School-teaching  also  seems  to  be  fraught  with  danger. 

The  question  of  social  position  as  a  predisposing 
element  is  often  erroneously  treated  by  writers  both 
lay  and  medical.  Neurasthenia  is  by  no  means  an 
affection  which  is  confined  to  the  wealthy.  On  the 
contrary,  it  forms  about  40  per  cent,  of  the  diagnoses 
entered  upon  the  records  of  the  nervous  department  of 
the  Boston  City  Hospital,  and  the  same  fact  probably 
holds  true  as  regards  the  hospitals  of  other  large 
cities. 

As  already  said,  the  belief  that  Americans,  as  a 
race,  are,  by  virtue  of  inherent  peculiarities,  espe- 
cially liable  to  nervous  breakdown  is  altogether  erro- 
neous. The  error  probably  arises  from  the  careless 
classification  as  Americans  of  all  denizens  of  this 
country  regardless  of  origin.  The  real  fact  of  the 
matter  is  that  the  Semitic  race  furnishes  by  far  the 
greatest  quota  of  nervous  sufferers.. 

As  to  the  time  of  life  at  which  the  affection  most 
commonly  appears,  it   may  be  stated,  as   a   general 


SYMPTOMS   OF  NEURASTHENIA.  285 

rule,  that  the  period  between  the  second  and  fifth 
decades  stands  preeminent,  although  cases  are  not  in- 
frequently met  with  at  both  earlier  and  later  periods. 

On  the  immediate  or  exciting  causes  of  neuras- 
thenia, there  is  no  need  of  elaborate  argumentation. 
They  may  be  stated  categorically  in  the  following 
order:  over-work,  whether  physical  or  mental,  and 
prolonged  morbid  emotional  excitement,  such  as 
worry,  anxiety,  vexation,  and  grief. 

Symptoms. — If,  as  has  been  stated,  it  is  upon  the 
perfect  integrity  of  the  fine  adjustment  of  the  nervous 
mechanism  that  the  healthy  function  of  all  the  other 
organs  of  the  body  depends,  and  if  neurasthenia  is  to 
be  looked  upon  not  only  as  a  pathologic  fatigue  of 
the  nervous  system,  but  also  as  a  morbid  irritability, 
we  should  expect  to  find  in  a  given  case  symptomatic 
evidence  both  of  degraded  organic  function  and  of 
over-reaction  to  environment.  And  this  is  exactly 
what  obtains.  The  check-rein  of  the  nervous  centers 
being  loosed,  the  bodily  functions  run  riot,  and  the 
suflferer  presents  symptoms  of  disturbance  of  diges- 
tion, circulation,  secretion,  and  of  the  sexual  func- 
tions. Nor  are  these  all.  The  strict  domain  of  the 
nervous  system  contributes  its  quota  to  the  morbid 
complex,  and  we  find  the  victim  also  offering  symp- 
toms of  disturbed  motion  and  sensation,  both  com- 
mon and  special,  and  of  perverted  intellection.  He, 
or  she,  is  weak  and  incapable  of  sustained  muscular 
effort,  as  is  easily  shown  by  the  diminishing  power  of 
successive  hand-grasps,  and  by  the  tremulousness 
which  accompanies  even  the  slightest  outputs  of 
muscular  force. 

The  sensorv  disturbances  are  of  the  most  varied 


286  THE   BRAIN  AND   NERVOUS  SYSTEM. 

type.  Ill  many  cases  there  are  actual  pains  in 
various  parts  of  the  extremities  and  trunk;  in  others 
areas  of  heat  or  cold  are  complained  of.  Especially 
annoying  are  the  headaches,  which  are  sometimes 
referred  to  the  top  of  the  skull  and  sometimes  to 
the  base,  and  when  in  the  latter  situation,  there  is 
also  experienced  a  feeling  as  if  the  head  were  too 
heavy  for  the  shoulders,  or  as  if  it  were  being  con- 
stantly pulled  back  by  the  neck  muscles.  Often  the 
spine  is  tender  throughout  its  entire  length,  at  times 
exquisitely  so.  Tender  spots  are  also  found  in  vari- 
ous regions  of  the  trunk,  notably  in  -the  region 
of  the  breasts  and  over  the  stomach,  and  patients 
often  complain  of  numbness  and  pain  extending 
from  the  elbow  along  the  inner  border  of  the  fore- 
arm into  the  ring  and  little  fingers,  the  latter  annoy- 
ance being  most  commonly  experienced  on  awak- 
ing in  the  morning.  Not  infrequently  dull,  dragging 
aches  in  the  extremities  take  the  place  of  actual  pain, 
and  in  addition  to  the  aching  there  will  be  present 
curious  sensations,  "as  though  the  blood  were  bub- 
bling in  the  veins,"  or  "as  though  the  heart  were 
beating  all  over  the  arms  or  legs." 

The  disturbances  of  the  special  senses  are  often 
very  marked,  one  of  the  earliest  being  a  blurring  of 
the  vision  on  using  the  eyes  for  any  length  of  time. 
This  may  become  so  pronounced  that  the  patient  is 
totally  unable  to  perform  any  labor,  such  as  sewing, 
reading  or  writing,  which  requires  steady  fixation  of 
vision  for  any  length  of  time.  The  auditory  annoy- 
ances usually  take  the  form  of  adventitious  sounds 
in  the  ears,  such  as  ringing,  buzzing,  whistling, 
singing,    roaring,    etc.,    hearing   itself    never    being 


SYMPTOMS   OF  NJWRAS'rilENIA.  287 

seriously  impaired.  Disorders  of  smell  are  not  eom- 
mon,  but  those  of  taste  are  frequently  complained  of; 
the  sufferer  saying  that  "nothing  tastes  right,"  or 
that  there  is  a  bitter  or  a  salty  taste  in  the  mouth, 
without  any  reference  to  the  taking  of  food.  The 
disturbances  in  the  intellectual  sphere  are  very  strik- 
ing and  often  causative  of  the  greatest  mental 
anguish.  Finding  himself  incapable  of  fixing  his 
attention  for  any  length  of  time  without  great  physi- 
cal discomfort,  the  patient  soon  begins  to  fear  that  he 
is  losing  his  mind,  and  this  leads  him  into  a  habit  of 
introspection  which  is  often  most  pernicious  in  its 
consequences.  To  the  fear  of  insanity  is  shortly 
added  a  host  of  other  fears,  which  so  limit  the 
capacity  for  initiation  that  the  patient's  friends  often 
have  to  lend  him  their  aid  in  the  accomplishment  of 
the  most  commonplace  undertakings.  He  becomes 
emotional  and  cannot  bear  to  read  of  accidents, 
murders,  or  sudden  deaths  from  apoplexy  or  heart 
disease.  His  sleep  is  troubled,  and  he  awakes  more 
tired  in  the  morning  than  when  he  went  to  bed  the 
night  before.  Often  on  closing  his  eyes  in  bed  he 
has  sudden  spasmodic  jerkings  of  his  legs,  or  a  feel- 
ing as  of  falling.  Real  insomnia  does  at  times  occur, 
but  most  nervous  sufferers  very  much  underestimate 
the  actual  amount  of  sleep  obtained. 

The  digestive  disturbances  are  varied,  but  they 
most  frequently  consist  in  an  inabilitv  to  digest 
starchy  food.  Patients  complain  that  everything  they 
eat  rests  like  a  great  lump  of  lead  in  the  stomach, 
and  the  gas  arising  from  the  fermentative  processes 
going  on  in  the  stomach  often  interferes  to  such  a 
degree  with  the  heart's  action  that  it  becomes  accel- 


288  THE  BRAIN  AND  NERVOUS  SYSTEM. 

er^ted  and  irregular — "  feels  as  though  it  turned  over 
at  times."  Sometimes  there  is  a  faintness  or  "all- 
goneness"  within  an  hour  or  so  after  taking  food. 
The  movements  of  the  bowels  are  capricious,  but 
constipation  is  more  common  than  diarrhea.  As  has 
been  stated,  the  heart's  action  is  frequently  interfered 
with  by  the  digestive  troubles,  but  aside  from  this 
all  sorts  of  anomalies  of  force  and  rhythm  may  occur 
independently  and  give  rise  to  most  intense  anxiety. 
The  pulse  is  often  heard  in  the  ear  by  the  patient 
himself  when  the  head  is  lying  on  the  pillow,  or  felt 
whenever  two  parts  of  the  body  are  brought  in  con- 
tact. The  vasomotor  apparatus  of  the  blood-vessels 
is  frequently  so  irritable  that  sudden  flushings  and 
pallors  are  common.  The  secretions  are  usually 
more  or  less  generally  interfered  with,  and  the  patient 
is  often  harassed  by  profuse  and  annoying  sweatings, 
which  may  occur  either  by  day  or  by  night  and  may 
be  general,  or  confined  to  the  hands,  or  even  to  one 
surface  of  an  extremity.  Extreme  dryness  of  the 
mouth  is  complained  of  in  certain  instances,  in  others 
salivation.  Frequent  micturition  is  common.  Dis- 
turbances in  the  sexual  sphere  often  find  a  prominent 
place  in  the  morbid  train.  In  women  analogous 
symptoms  occur  in  the  same  sphere,  but  with  very 
much  greater  infrequency. 

Fortunately,  not  every  case  presents  all  of  the 
morbid  conditions  at  the  same  time,  or  at  any  time; 
but  a  large  number  run  nearly  through  the  gamut  if 
they  are  at  all  prolonged.  This  is  especially  true  of 
those  in  which  introspection  plays  a  prominent  part, 
and  these  are  generally  recruited  from  among  the 
educated  classes.     With  such  people  a  little  medical 


PATHOLOGY  01'   NEURASTHENIA.  289 

knowledge  is  a  dangerous  thing.  They  are  niorljidly 
alert  for  new  symptoms,  which,  owing  to  the  intense 
power  of  mind  over  matter,  are  not  long  in  presenting 
themselves,  and  these  they  proceed  to  interpret  in  a 
fashion  utterly  false  and  illogic. 

Pathology. — Of  the  pathologic  substratum  of 
neurasthenia  little  is  thus  far  definitely  known,  but 
as  we  are  morally  certain  that  such  intense  fatigue  of 
the  nervous  system  as  is  logically  assumed  to  be 
present  in  this  condition  cannot  exist  without  leaving 
some  structural  imprint,  it  may  prove  interesting  to 
note  briefly  the  results  obtained  by  the  finer  methods 
of  investigation  in  animals,  whose  nervous  tissues 
had,  either  by  electric  stimulation  or  by  prolonged 
normal  exercise  of  function,  been  brought  into  the 
condition  of  exhaustion.  In  these  experiments  the 
results  obtained  were  always  the  same  and  had  to  do 
with  the  nerve-cells.  These  latter  were  found  to  be 
altered  in  size  and  shape,  and  in  their  constituent 
elements;  the  alteration  being  in  the  form  of  a  gen- 
eral shrinkage,  with  irregularity  of  outline  of  the 
cell-nucleus  and  of  the  protoplasm.  The  chemic 
reaction  was  also  altered.  A  further  discovery  of 
interest  was  that  cells  recovered  after  electric  stim- 
ulation, but  that  recovery  was  slow,  twenty-four 
hours'  rest  scarcely  sufficing  to  bring  it  about  after 
five  hours'  stimulation. 

The  above  results  of  experimental  investigation 
are  most  interesting  and  suggestive,  and,  while  we 
are  not  warranted  in  sayiug  absolutely  that  the  same 
pathology  holds  good  for  nervous  exhaustion  in  the 
human  species,  it  requires  no  great  stretch  of  the 
imagination    to   conceive  of  similar  changes   taking 

19 


290  THE  BRAIN  AND  NERVOUS  SYSTEM. 

place  in  this  latter  condition.  The  symptomatic 
aspect  of  the  problem  is  certainly  more  than  sufficient 
warrant  for  such  belief 

Prognosis. — The  question  of  the  duration  of  the 
affection  is  not  the  least  important  with  regard  to  it. 
This,  however,  depends  upon  so  many  and  so  varied 
conditions  that  the  outcome  of  the  individual  case 
must  be  decided  on  its  merits.  Recovery  up  to  a 
certain  degree  is  the  rule,  though  at  times  it  may  be 
complete;  but  this  takes  place  usually  only  after  a 
long  and  discouraging  siege  which  is  marked  by 
many  relapses.  Patients  will  often  lose  in  a  very 
short  period  whatever  of  gain  they  may  hav-e  been 
many  weeks  in  accomplishing.  Hardly  any  of  them 
come  out  of  the  conflict  unscathed,  and  though  many 
recover  sufficiently  to  cope  with  the  ordinary  duties 
and  trials  of  life,  they  are  never  quite  capable  of 
weathering  its  real  storms. 

Hygienic  Treatment. — The  subject  of  treatment 
proper  does  not  come  within  the  scope  of  this  article, 
the  point  at  issue  being,  rather,  by  what  "  effiarts  and 
avoidances,"  as  Prof.  Putnam  puts  it,  by  adherence 
to  what  hygienic  laws,  in  other  words,  we  may  pre- 
vent ourselves,  or  those  confided  to  our  care,  from 
drifting  upon  the  shoals  of  nervous  and  mental  degra- 
dation. In  this  connection,  however,  too  narrow  an 
interpretation  must  not  be  put  upon  the  scope  of  these 
laws. 

We  are  about  to  deal  with  matters  mental  as  well 
as  physical,  and  are  therefore  constrained,  in  consid- 
ering the  health  of  such  a  metaphysical  structure 
as  the  mind,  for  instance,  to  embrace  the  moral  as 
well  as  the  physical  aspects  of  the  problem.     And 


THE  ABUSE    OE  ALCOHOL.  29 1 

here  it  may  be  stated  that  the  hygienic  principles  to 
be  advocated  by  no  means  apply  solely  to  the  preven- 
tion of  that  single  aberration  of  nervous  and  mental 
health  which  has  been  described  under  the  term  neu- 
rasthenia. On  the  contrary,  they  apply  with  equal 
pertinency  to  a  very  large  number  of  equally  pre- 
ventable diseases  of  the  brain  and  nervous  system. 

Every  physician  whose  duties  bring  him  much  in 
contact  with  the  victims  of  nervous  and  mental  dis- 
ease will  unhesitatingly  endorse  the  statement  that 
the  nervous  and  mental  health  of  a  nation  is  in  direct 
relation  to  its  moral  health.  The  greatest  scourges 
of  the  nervous  system  are  syphilis  and  alcohol,  and  it 
is  a  distressing  fact  that  many  of  the  paralytics  who 
go  dragging  their  painful  way  along  toward  a  prema- 
ture grave,  and  that  hundreds  of  other  people  who, 
in  the  very  prime  of  life,  meet  with  absolute  annihi- 
lation of  their  intellectual  faculties,  are  simply  the 
victims  of  their  own  immoderate  appetites  and  un- 
restrained licentiousness. 

The  Abuse  of  Alcohol. — The  physiologic  chemists 
tell  us  that  alcohol  received  into  the  system  is  there 
consumed  in  the  same  way  as  starch  and  sugar,  and 
that  the  energy  yielded  by  it  becomes  kinetic  in  the 
form  of  heat — is  transformed  into  muscular  strength; 
further,  that  it  takes  the  place  of  other  food-ingre- 
dients in  the  actual  nourishment  of  the  body.  These 
are  the  facts  of  physiologic  research,  of  laboratory 
experimentation,  and  as  such  are  beyond  cavil. 

Few  physicians  of  experience  wnll  deny  the  great 
advantage  to  be  derived  from  alcohol  in  combating 
the  poison  of  fevers  and  in  the  maintenance  of  nutri- 
tion in  certain  debilitated  states :    but  neither  will 


292  THE  BRAIN  AND  NERVOUS  SYSTEM. 

they  be  inclined  to  deny  that  the  kinetic  energy  stored 
up  in  the  healthy  tissues  of  a  man  by  the  introduction 
of  one  or  two  ounces  of  alcohol  is  likely  to  expend 
itself  in  ways  detrimental  to  that  individual's  future 
nervous  and  mental — in  fact,  his  whole  physical  and 
moral  welfare. 

Alcohol  is  certainly  a  poison  for  nervous  tissues,  and 
when  taken  constantly  into  the  system,  even  though 
the  daily  amount  be  small,  often  produces  organic 
changes.  By  persons  of  nervous  temperament,  so- 
called,  the  use  of  alcoholic  stimulants  is  especially  to  be 
avoided,  since  the  discomfort  of  the  after-depression, 
even  from  the  use  of  very  small  amounts,  more  than 
counterbalances  the  temporary  sense  of  increased  ner- 
vous energy  produced. 

The  question  of  the  advisability  of  the  use  of  tea, 
coffee,  and  tobacco  allows  of  a  wider  range  of  debate. 
A  cup  of  coffee  in  the  morning  does  no  harm,  and  is 
often  conducive  to  a  satisfactory  movement  of  the 
bowels.  The  excessive  consumption  of  tea,  to  which 
many  women  of  nervous  habit  are  addicted,  often  to 
the  exclusion  of  nutritious  food,  is,  however,  particu- 
larly to  be  deprecated.  To  the  man  of  weak  nerves 
the  use  of  tobacco  will  never  prove  anything  but 
harmful. 

Of  the  virulency  of  the  syphilitic  poison  on  the  ner- 
vous system  and  the  subtle  way  it  invades  it — often- 
times years  after  the  primary  inoculation — volumes 
have  been  written.  Let  it  suffice  to  repeat  here  that 
of  the  large  number,  especially  of  the  young  and 
middle-aged,  who  are  yearly  stricken  with  a  sudden 
paralysis  of  one  side,  or  one  extremity,  or  who,  for  no 
other  apparent  reason  than   the   commonly  alleged 


OVEK-WORk'.  293 

"over-work,"  sink  gradually  into  the  gloom  of  com- 
plete dementia,  the  majority  arc  its  victims. 

The  lesson  in  moral  hygiene  thus  relentlessly  taught 
leads  directly  to  the  preaching  of  the  necessity  for  the 
early  and  firm  building  of  character  as  a  nervous  and 
mental  safeguard.  American  parents  are  neither  more 
indifferent  nor  careless  as  regards  the  mental  and  moral 
welfare  of  their  children  than  people  of  other  coun- 
tries, although  certain  pessimistic  writers  on  this  sub- 
ject would  have  us  think  the  contrary.  They  do  need, 
however,  to  have  it  firmly  impressed  on  their  minds 
that,  in  a  country  like  ours,  where  independence  is 
the  watchword,  this  independence  cannot  with  safety 
be  made  to  apply  to  their  relations  with  Nature;  and, 
further,  that  if  they  would  have  their  children  pre- 
serve their  mental  and  nervous  equilibrium  in  the 
presence  of  the  appalling  vicissitudes  of  fortune  so 
commonly  observed  in  this  country,  they  must  early 
inculcate  such  saving  principles  as  fortitude,  self- 
denial,  and  self-control. 

OVER=WORK. 

As  the  direct,  or  exciting,  cause  of  nervous  and 
mental  breakdown  much  emphasis  has  been  laid  upon 
over-work,  both  physical  and  mental,  and  this  leads 
to  a  consideration  of  the  measures  which  may  be  taken 
to  avoid  it.  To  formulate  rules,  however,  which  will 
fit  every  case  is  clearly  impossible,  since  the  w^hole 
subject  resolves  itself  into  the  question  of  personal 
limitations.  Everyone  at  all  observant  of  his  bodily 
and  mental  conditions  must  be  fully  cognizant  of 
what  Dr.  Holmes^  called  the  "  curve  of  health."     To 

1  Oliver  Wendell  Holmes,  Over  the  Teacups. 


294  THE  BRAIN  AND  NERVOUS  SYSTEM. 

use  this  author's  own  words  :  "  It  is  a  mistake  to  sup- 
pose that  the  normal  state  of  health  is  represented  by 
a  straight  horizontal  line.  Independently  of  the  well- 
known  causes  which  raise  or  depress  the  standard  of 
vitality,  there  seems  to  be — I  think  I  may  venture  to 
say  there  is — a  rhythmic  undulation  in  the  flow  of  the 
vital  force.  The  '  dynamo  '  which  furnishes  the  work- 
ing powers  of  consciousness  and  action  has  its  annual, 
its  monthly,  its  diurnal  waves,  even  its  momentary 
ripples,  in  the  current  it  furnishes.  There  are  greater 
and  lesser  curves  in  the  movement  of  every  day's  life — 
a  series  of  ascending  and  descending  movements,  a 
periodicity  depending  upon  the  very  nature  of  the 
force  at  work  in  the  living  organism.  Thus  we  have 
our  good  seasons  and  our  bad  seasons,  our  good  days 
and  our  bad  days,  life  climbing  and  descending  in 
long  or  short  undulations,  which  I  have  called  the 
curve  of  health." 

In  this  very  shrewd  observation  are  contained  the 
elements  of  a  practical  and  satisfactory  working 
hypothesis.  It  teaches  that  everyone  should  strive 
to  give  due  heed  to  the  ebb  and  flow  of  his  vital 
forces  and  regulate  his  periods  of  activity  and  rest 
accordingly. 

Mental  Over- work. — Many  persons  are  either 
ignorant  or  unmindful  of  the  fact  that  intellectual 
activity  has  a  tangible  physiologic  substratum,  but 
for  proof  that  it  has  we  need  only  to  recall  the  pict- 
ure which  someone  has  drawn  for  us  of  a  literary 
man  hard  at  work,  with  an  ice-cap  on  his  head  and 
his  feet  in  a  pail  of  hot  water. 

Physiologists  have  shown  that  intellectual  activity 
is  always   accompanied   by   cerebral   hyperemia  ;  in 


MENTAL    OVKR-VVOKK.  295 

other  words,  by  a  marked  increase  in  the  amount  of 
blood  contained  in  the  vessels  of  the  brain.  This 
being  so,  we  should  refrain  from  bringing  about  this 
condition  at  a  time  when  the  blood  thus  attracted  to 
the  brain  is  urgently  needed  for  the  proper  functional 
activity  of  the  bodily  processes,  notably  digestion. 
As  an  example  of  what  often  results  from  an  infrac- 
tion of  this  rule  we  have  need  only  to  look  to  the 
large  number  of  cases  of  stomach  and  intestinal  in- 
digestion in  brain-workers  who  persist  in  pursuing 
their  intellectual  avocations  immediately  after  eat- 
ing. It  is  obvious  then  that  intellectual  and  diges- 
tive processes  cannot,  with  any  degree  of  comfort,  be 
called  into  play  at  the  same  time. 

The  morning  seems  to  be  the  time  when  the  brain, 
after  the  repair  occasioned  by  a  night's  rest,  possesses 
the  most  "verve,"  and  it  is  then  that  the  bulk  of  in- 
tellectual performance  should  take  place.  Almost 
from  the  beginning  of  the  day  the  process  of  running 
down  goes  on,  and  this  running-down  process  seems 
to  reach  its  maximum  at  about  four  o'clock  in  the 
afternoon.  It  is  at  this  hour  certainly  that  the  vital- 
ity of  the  nervously  weak  often  reaches  its  lowest 
ebb.  There  is,  however,  a  subsequent  increase  in 
vigor,  which  is  derived  from  taking  the  evening's 
meal,  but  the  blood-supply  to  the  brain  has  already 
begun  to  be  influenced  by  the  waste  products  of  the 
active  cells.  These  waste  products  ultimately  accu- 
mulate faster  than  they  are  removed,  render  cerebral 
activity  more  and  more  difficult,  and  finally  suppress 
it  to  such  a  degree  that  sleep  intervenes. 

This  is  the  way,  then,  that  Nature,  if  left  to  her- 
self, would  regulate  the  matter  of  waste  and  repair, 


296  THE  BRAIN  AND  NERVOUS  SYSTEM. 

and  it  would  certainly  be  of  great  benefit  to  brain- 
workers  if  they  took  the  hint  from  her  and  arranged 
their  periods  of  mental  activity  and  rest  accordingly, 
even  though  they  did  so  only  to  the  extent  of  getting 
that  portion  of  their  brain-rest  which  is  comprised  in 
sleep,  during  the  hours  between  ten  o'clock  at  night 
and  eight  in  the  morning.  With  all  due  respect  to 
opinions  to  the  contrary,  the  brain-worker  requires 
more  sleep  than  the  laboring-man,  and  he  is  certainly 
doing  himself  an  injustice,  against  which  his  nervous 
system  will  sooner  or  later  rebel,  if  he  attempts  to  get 
along  with  less  than  eight  hours. 

Every  now  and  then  we  are  treated  to  an  article  in 
some  popular  magazine  which  informs  us  that  some 
favorite  author  carries  on  his  work  at  hours,  and  on 
the  strength  of  an  amount  of  sleep,  which  set  all  the 
laws  of  Nature  at  defiance.  Whether  this  perform- 
ance is  exploited  with  the  idea  of  stimulating  the 
ambitious  young  man  or  woman  to  do  likewise  or 
not,  is  not  known,  but  it  certainly  does  not  take 
much  critical  acumen  to  detect  in  the  work  of  such 
an  author  positive  evidence  of  a  lack  of  sustained 
effort  which  is  greater  than  can  be  accounted  for  on 
ordinary  grounds.  At  all  events  the  world  would  be 
far  better  off  if  it  were  spared  much  of  the  material 
which  comes  to  us  in  the  guise  of  literature,  but  is  in 
reality  the  product  of  the  same  sort  of  cerebration 
that  produces  bad  dreams  and  nightmare.  Occa- 
sionally great  thoughts  will  insist  on  forcing  their 
way  into  the  consciousness  during  the  dead  of  night, 
but  these  occasions  are,  on  the  whole,  so  rare  that  we 
may  with  safety  incur  the  brief  loss  of  sleep  which 
the  recording  of  them  on  paper  entails.     Unfortunate 


WOA'A'V.  297 

examples  of  the  effects  of  intellectual  einploynieiit 
during  the  normal  sleeping-hours  are  the  cases  of 
neurasthenia  in  editors  and  reporters  employed  on 
morning  newspapers. 

Worry. — The  brain  is  an  organ  which,  under 
proper  training,  is  capable  of  performing  an  immense 
amount  of  work,  provided  only  that  the  work  is  of  a 
varied  character  and  does  not  induce  a  correspond- 
ing amount  of  emotional  disquietude.  The  impor- 
tance of  the  emotions,  especially  the  depressing  emo- 
tions such  as  grief,  anxiety,  and  worry,  as  factors  in 
brain  exhaustion,  cannot  easily  be  overestimated.  It 
is  a  theme,  however,  which  has  been  harped  upon  so 
much  by  writers  on  nervous  diseases  that  the  country 
at  large  seems  at  last  to  be  awakening  to  the  fact 
that  some  united  effort  should  be  made  to  obtain 
emancipation  from  at  least  one  of  the  morbid  list, 
and  in  consequence  we  now  have  the  "Don't 
Worry  "  Society,  among  whose  members  are  many 
hundreds  of  brain-workers.  Such  a  popular  move- 
ment is  certainly  commendable  and  will  no  doubt 
lead  to  much  beneficial  result.  The  old  saying  that 
it  is  not  work  but  worry  that  kills  is  particularly  rele- 
vant with  respect  to  brain-work.  A  mere  fit  of  low 
spirits,  for  the  time  being  may  cripple  a  man  in  the 
use  of  his  intellectual  faculties,  but  circumstances 
still  tend  to  influence  him,  and  he  can  review  his 
position,  even  though  he  does  so  gloomily.  His  sav- 
ing clause  lies  also  in  the  fact  that  the  turn  of  events 
and  the  moderating  influence  of  time  produce  restora- 
tion of  physiologic  and  psychologic  equilibrium. 
Far  different  is  it,  however,  with  the  man  who  is 
constantly  worried,  since    neither  time   nor  circum- 


298  THE  BRAIN  AND  NERVOUS  SYSTEM. 

stance  can  do  more  for  him  than  to  press  down  the 
balance  more  heavily  upon  the  side  of  both  physio- 
logic and  psychologic  unrest. 

The  Need  of  Mental  Recreation. — With  a  terri- 
ble emotional  incubus  fastened  upon  a  brain  which 
is  being  forced  to  work  in  a  single  rut,  as  it  is  in  the 
case  of  inventors,  speculators,  and  promoters  of 
schemes,  it  is  easy  to  see  why  it  soon  comes  to  the 
end  of  its  forces;  and  the  hygienic  hint  therein  con- 
tained is  equally  obvious.  America  is  justly  proud 
of  her  banker  poet,^  who  has  found  abundant  time  to 
enrich  the  world  of  letters  while  still  engaged  in  a 
pursuit  which  often  taxes  the  mental  and  emotional 
stability  of  its  followers  to  its  utmost.  Why  should 
we  not  also  produce  litterateurs  from  the  stock- 
exchange,  or  art  connoisseurs  from  among  the  ranks 
of  other  callings,  the  slavish  pursuit  of  which  is 
frauo-ht  with  such  disastrous  results  to  the  nervous 
system  ?  These  are  only  a  few  ways  that  brain-rest 
may  be  obtained,  but  they  are  sufficient  to  indicate 
what  brain-rest  means.  It  is  a  very  great  mistake  to 
suppose  that  cerebral  activity  can  ever  be  brought  to 
a  stand-still.  The  brain  is  an  organ  which  never 
ceases  its  activity,  not  even  during  sleep;  of  this  we 
are  often  painfully  made  aware  when  we  are  suddenly 
awakened  into  the  shivering  consciousness  of  having 
experienced  a  bad  dream.  When  we  speak,  there- 
fore, of  measures  other  than  sleep  that  may  be 
adopted  to  obtain  rest  for  the  brain,  we  merely  mean 
those  which  aim  at  diverting  its  activity  into  chan- 
nels that  will  affiDrd  a  pleasant  or  soothing  reaction 
upon  consciousness. 

1  Edmund  Clarence  Stedman. 


71IE   NEED    OE  MENTAL   RECREATION.  299 

The  truth  of  this  fact  is  strongly  borne  in  upon 
us  by  the  numberless  failures  of  brain-workers  to 
obtain  needed  rest  through  efforts  which  entirely 
neglect  to  give  it  its  due  weight.  It  is  certainly  a 
great  mistake  to  try  to  escape  the  Nemesis  of  an 
over-worked  and  harassed  brain  by  a  feverish  tour 
of  the  continent,  or  by  a  few  weeks'  unwilling  sojourn 
within  the  deadly  dull  confines  of  a  country  village. 
The  familiar  and  much-quoted  lines  : 

"  Coelum  non  animam  mutant, 
Qui  trans  mare  currunt." 
(They  change  their  skies  but  not  themselves, 
That  cross  the  seas.") 

are  extremely  pertinent  to  the  case  in  point,  and 
should  be  memorized  by  all  who  are  striving  to  work 
out  the  mental  and  nervous  salvation  of  the  brain- 
worker. 

It  is  clearly  impossible  for  the  average  stock- 
broker or  scheme-promoter  to  become  a  shining  light 
in  the  world  of  art  or  letters.  That  fact  is  fully 
appreciated  in  the  proposition  set  forth.  There  is 
nothing  lost,  however,  if  such  a  person's  efforts  are 
not  crowned  with  success,  whereas  the  gain  from  the 
healthful  mental  gymnastics  involved  is  often  incal- 
culable. 

Thus  far  two  general  outlets  for  high-pressure  cere- 
bration have  been  mentioned;  there  are  many  others, 
and  one  of  the  most  valuable  is  the  cultivation  of 
fads.  Fads  may  be  said  to  constitute  a  perfect  men- 
tal antitoxin  for  the  poison  generated  b}'^  cerebral 
over-activity.  It  is  not  necessary  that  they  should 
be  at  all  expensive  or  involve  a  great    amount  of 


300  THE  BRAIN  AND  NERVOUS  SYSTEM. 

time.  The  brain-worker  whose  purse  will  permit  of 
no  greater  drain  than  that  which  is  involved  in  the 
fad  of  stamp-collecting  on  a  small  scale,  has  just  as 
great  a  chance  for  nervous  salvation  as  the  person 
whose  bank  account  warrants  the  acquisition  of  a 
museum  of  art-treasures,  and  the  writer  feels  confident 
that  he  has  seen  complete  mental  prostration  averted 
in  one  instance  by  an  overwrought  young  woman 
turning  her  attention  to  the  study  of  the  different 
weaves  of  oriental  rugs.  Among  other  fads  which 
are  helpful  may  be  mentioned  the  collection  of  book- 
plates, rare  books  (which  are  often  not  expensive, 
though  pleasantly  elusive),  old  china  and  furniture, 
and  old  prints.  The  list  might  be  prolonged  in- 
definitely, but  it  will  suffice  to  say  that  many  not 
here  enumerated  will  be  suggested  by  a  study  of  the 
circumstances  surrounding  the  individual  case. 

To  all  this  will  undoubtedly  be  objected  the  plea 
of  lack  of  time.  The  answer  to  arguments  formed 
on  such  a  flimsy  basis  is,  that  all  time  which  is  spent 
in  preparing  one's  self  as  a  candidate  for  a  sanita- 
rium, or,  worse  still,  for  a  lunatic  asylum,  is  like  the 
proverbial  edged  tool  in  the  hands  of  children  and 
fools. 

Physical  Over-work. — Next  in  importance  to 
brain  over-work,  as  regards  nervous  and  mental  well- 
being,  comes  the  question  of  physical  over-work. 
The  two  subjects  are,  indeed,  closely  interrelated,  and 
what  has  been  said  of  the  former  from  the  standpoint 
of  pathology  and  hygiene  applies  very  forcibly  to 
the  latter.  All  motor  activity,  as  has  been  shown,  is 
the  result  of  nervous  energy;  hence  what  we  term 
bodily  fatigue  is  in   reality  nervous   fatigue.     This 


PHYSICAL    OVKRIVOKK.  30I 

does  not  imply,  however,  that  the  muscles  do  not 
undergo  changes  as  the  result  of  activity;  they  cer- 
tainly do,  but  such  changes  are  only  of  secondary 
importance  as  compared  with  those  which  are  at  the 
same  time  produced  in  the  nervous  system. 

The  changes  pointed  out  'by  Hodge  as  occurring  in 
the  cells  of  the  central  nervous  system  of  animals 
during  extreme  bodily  fatigue  have  already  been 
enumerated.  There  is  still  further  evidence  which 
goes  to  show  that  these  central  changes  do  not  occur 
alone,  but  are  accompanied  by  others  that  involve 
the  intermediate  portion  of  the  neuro-muscular  sys- 
tem, which  we  call  the  "terminal  plate." 

According  to  Abelous,'  "spontaneous  curarization"^ 
takes  place  in  fatigued  muscles  through  the  action  of 
toxic  substances  produced  by  muscular  action.  This 
he  shows  by  the  following  experiment:  A  current  of 
electricity  was  passed  through  the  body  of  a  frog  from 
mouth  to  anus  in  such  a  way  as  to  produce  complete 
tetanization  in  a  given  time.  The  current  was  then 
shut  off  and  the  frog  left  undisturbed  for  a  time.  On 
reopening  the  circuit  it  was  found  that  the  muscles, 
tired  after  the  first  excitation,  were  no  longer  capable 
of  a  new  tetanization.  It  was  discovered,  however, 
that  if  the  nerve  of  the  left  hind  leg  were  excited, 

'  Abelous,  quoted  by  Brissaud,  Lefoiis  sur  les  Maladies  Neiueuses,  Paris, 

1895.  P-  323- 

*  By  cuvarization  is  meant  an  action  similar  to  tliat  produced  by  a  drug 
called  curare  (or  woorari).  This  latter  is  an  extract  of  uncertain  compo- 
sition, and  is  prepared  and  used  by  the  natives  of  South  America  as  an 
arrow-poison.  The  effect  of  immoderate  doses  of  it  upon  the  nervous  sys- 
tem is  to  cause  great  muscular  weakness  and  paralysis  of  all  the  voluntary 
muscles.  The  ends  of  the  motor  and  sensoi"y  nerves  are  paralyzed  ;  the 
former  being  affected  first. 


302  THE   BRAIN  AND   NERVOUS  SYSTEM. 

contraction  was  insignificant  or  nil^  whereas  excita- 
tion of  the  nerve  of  the  right  hind  leg — whose  artery 
had  been  tied — produced  strong  contractions  in  this 
limb. 

The  conclusion  drawn  by  Abelous  from  this  ex- 
periment was  that  the  toxic  substances  produced  in 
the  body  by  the  tetanization  of  the  muscles  exerted 
their  paralyzing  influence  through  the  circulation  and 
upon  the  end-plates  of  the  neuro-muscular  system 
rather  than  directly  upon  either  the  nerves  or  the 
muscles  proper.  As  nervous  and  muscular  irritability 
was  still  preserved  in  the  right  hind  leg,  whose  blood- 
supply  was  cut  off  by  tying  the  artery,  and  not  in 
the  left,  where  the  blood-flow  remained  unimpeded, 
Abelous's  conclusion  seems  to  be  abundantly  war- 
ranted. The  results  thus  obtained  from  the  study  of 
fatigue  experimentally  produced  lead  us  to  consider 
whether  or  not  they  have  physiologic  analogues; 
whether,  in  a  word,  the  state  of  the  muscles  of  a  man 
who  is  fatigued  may  be  likened  to  that  of  the  teta- 
nized  muscles  of  a  frog.  In  the  stiffness  of  the  limbs 
which  follows  a  prolonged  walk  there  would  seem  to 
be  a  beginning  tetanization.  And  as  to  the  sensation 
which  accompanies  this  condition,  it  would  certainly 
seem  that  we  are  warranted  in  looking  upon  it  as  a 
sort  of  incipient  auto-intoxication. 

Both  classes  of  experiments,  that  of  Hodge  as  well 
as  that  of  Abelous,  are  extremely  suggestive,  and 
point  the  way  toward  a  clearer  conception  of  the 
whole  relation  between  nervous  and  muscular  activity. 
They  certainly  lead  us  to  be  sceptical,  to  say  the 
least,  as  to  the  absolute  necessity  of  the  building  up 
of  a  vigorous  muscular  system — with  all  the  output  of 


PHYSICAL    OVER-WOKK.  303 

energy  which  this  process  entails — as  a  safeguard  to 
the  maintenance  of  healthy  mental  and  nervous  bal- 
ance. 

On  this  point  may  be  quoted  once  more  that  very 
keen  observer,  Dr.  Holmes,'  whose  long  and  useful 
career  is  the  best  proof  of  the  wisdom  of  his  views. 
He  says:  "Do  not  think  that  a  robust  organization  is 
any  warrant  of  long  life,  nor  that  a  frail  and  slight  bodily 
constitution  necessarily  means  scanty  length  of  days. 
Many  a  strong-limbed  young  man  and  many  a  bloom- 
ing young  woman  have  I  seen  falling  and  dropping 
away  in  or  before  middle  life,  and  many  a  delicate 
and  slightly  constituted  person  outliving  the  athletes 
and  beauties  of  their  generation.  Whether  the  exces- 
sive development  of  the  muscular  system  is  compati- 
ble with  the  best  condition  of  general  health  is,  I 
think,  more  than  doubtful.  The  muscles  are  great 
sponges  that  suck  up  and  make  use  of  large  quantities 
of  blood,  and  the  other  organs  must  be  liable  to  suffer 
for  want  of  their  share." 

Basing  their  judgment  on  the  trite  aphorism,  ' '  Mens 
Sana  in  corpore  sano,"  many  enthusiasts  would  have 
us  believe  that  if  we  are  to  entertain  hopes  of  becom- 
ing intellectual  giants  we  must  set  about  acquiring 
the  muscular  force  of  a  dray-horse;  but  if  we  take  the 
trouble  to  consider  how  few  of  the  shining  lights  of 
pugilism  are  also  conspicuous  in  the  arena  of  art 
or  letters,  for  example,  the  fallacy  of  such  a  doctrine 
is  at  once  apparent. 

It  is  not  even  true  that  the  day  laborer,  possessed, 
as  he  generally  is,  of  a  fine  musculature,  is  equally 
gifted  in  the  matter  of  nervous  system.     The  deadly 

'  Holmes,  loc.  cit. 


304  THE  BRAIN  AND  NERVOUS  SYSTEM. 

monotony  of  his  avocation,  with  its  freedom  from 
emotional  reaction,  not  infrequently  proves  too  much 
for  his  mental  and  nervous  stability.  If  any  one 
desires  proof  of  this,  let  him  carry  stones  from  one  pile 
to  another  at  a  distance,  say,  of  fifty  feet,  and  when  the 
first  is  exhausted  begin  to  carry  the  combined  stones 
of  both  piles  back,  one  at  a  time,  until  both  are  heaped 
up  on  the  site  of  the  first.  It  will  not  require  many  rep- 
etitions of  this  process  to  convince  the  experimenter 
of  its  unquestioned  ability  to  produce  complete  mental 
and  nervous  demoralization.  Muscular  exercise,  like 
brain  exercise,  must,  in  order  to  be  potent  for  the  best 
good  of  the  mind  and  nervous  system,  be  such  as  to 
provoke  pleasurable  emotions. 

We  have  already  spoken  of  the  power  of  worry  to 
evoke  mental  exhaustion,  and  we  shall  not  have  far  to 
seek  for  illustrations  of  its  equal  capability  to  annihilate 
muscular  energy.  Contrast,  for  example,  the  utter 
weariness  produced  in  the  young  physician — if  he  be 
conscientious — by  his  first  few  cases,  with  the  fresh- 
ness with  which  his  older,  case-hardened  confrere 
accomplishes  his  daily  rounds;  or  the  physical  condi- 
tion of  the  mother  who  has  nursed  her  child  through 
a  long  illness,  with  that  of  the  paid  nurse  who  is  sub- 
jected to  the  same  amount  of  fatigue-producing  work 
without  the  emotional  strain. 

Regulated  Exercise. — In  thus  emphasizing  the 
meaning  and  danger  of  fatigue,  there  is  no  desire 
to  discourage  muscular  exercise.  The  aim  is  rather, 
by  force  of  contrast,  to  heighten  its  importance  when 
carried  out  with  due  consideration  to  hygienic  rules. 
The  majority  of  people  get  all  the  exercise  they  need 


GOLF.  305 

in  the  routine  of  daily  life;  it  is  for  the  sedentary  and 
nervously  constituted  persons  that  we  need  to  plan. 

For  the  former  a  daily  walk  of  three  or  four  miles 
in  the  open  air,  at  the  rate  of  about  three  miles  an 
hour,  is  sufficient;  for  the  latter  the  problem  is  much 
more  difficult  and  entails  a  study  of  the  individual 
case.  Some  nervous  invalids  are  incapable  of  exert- 
ing their  muscles  at  all  without  provoking  an  expendi- 
ture of  nervous  force  which  leaves  them  bankrupt  for 
weeks,  and  for  them  nothing  more  than  massage  and 
carefully  regulated  passive  motion  is  desirable.  Others 
suffer  from  what  may  be  termed  a  "paralysis  of  voli- 
tion," and  are  really  capable  of  enduring  a  great  deal 
more  than  they  think.  They  should,  therefore,  be 
handled  with  the  greatest  circumspection.  Their 
exercise  should  be  taken  in  the  open  air,  since  the 
monotonous  round  of  Indian  clubs,  chest-weights,  and 
dumb-bells  is  to  them  invariably  irksome  and  fatig- 
uing. These  persons  need  mental  as  well  as  physical 
gymnastics,  and  these,  in  the  writer's  opinion,  are 
most  abundantly  offered  by  golf. 

Golf  is  one  of  the  greatest  boons,  in  the  way  of  out- 
door exercise,  yet  offered  to  the  nervously  weak  of 
both  sexes.  It  is  excellent  from  an  esthetic  stand- 
point, because  the  player's  scene  of  action  is  a  con- 
stantly shifting  one  and  brings  him  face  to  face  with 
Nature  under  new  and  varied  aspects.  Nor  is  this 
its  only  virtue.  The  mind  finds  both  restful  and 
absorbing  occupation  in  the  calculation  of  distances 
and  in  regulating  the  coordination  of  the  muscles 
involved  in  the  stroke.  There  need  be  no  violent 
efforts,  no  hurry,  no  emulation;  and  the  player  mav 
always  stop  at  the  very  first  signs  of  fatigue.  Curiouslv 
20 


3o6  THE  BRAIN  AND  NERVOUS  SYSTEM. 

enough,  however,  the  golfer  is  usually  so  completely 
preoccupied  with  the  matter  of  ' '  hazards ' '  and 
' '  bunkers ' '  that  the  amount  of  ground  traversed  is 
not  appreciated,  and  delicate  women  often  say  that 
they  are  able  to  get  over  more  ground,  without  fatigue, 
in  pursuit  of  a  wayward  golf-ball  than  they  had  ever 
dreamed  of  in  their  most  ambitious  moments. 

Bicycling. — For  the  somewhat  more  vigorous  and 
self-reliant  neurasthenic  the  bicycle  is  an  excellent 
means  of  educating  the  nervous  system,  but  the  scope 
of  its  adaptability  is  limited  largely  to  male  sufferers. 
It  certainly  is  not  good  for  timid  and  apprehensive 
females,  and  attempts  on  the  part  of  such  to  conquer 
a  natural  aversion  for  it  should  be  encouraged  only 
in  a  very  limited  number  of  cases,  since  the  nervous 
outputs  these  attempts  involve  are  far  more  often 
attended  with  disastrous  than  with  happy  results. 

The  use  of  the  wheel  implies  work,  often  hard  work; 
but  it  has  a  saving  clause  in  the  fact  that  it,  even 
more  than  golf,  affords  opportunities  for  a  constant 
change  of  scene.  To  the  experienced  rider  the  pecu- 
liar sensation,  as  of  flying,  which  is  often  felt  while 
wheeling  along  a  pleasant  road  is  very  nerve-soothing, 
and  gives  him  a  sense  of  vigor  that  is  indescribable. 
Often  we  have  the  opportunity  to  witness  the  delight 
of  profoundly  nervous  but  plucky  patients  on  finding 
that  they  can  ride  the  wheel  several  miles  with  com- 
fort, whereas  they  cannot  cover  the  distance  of  a 
few  blocks  on  foot  without  great  mental  as  well  as 
physical  suffering.  And  in  some  cases  this  achieve- 
ment marks  the  turning-point  in  the  road  toward  the 
lecovery  of  nervous  health. 

Tennis   is   in   most   cases   much  too   violent   and 


HUNTING.  307 

exhausting  for  persons  of  weak  nerves,  but  both 
canoeing  and  boating  are  very  excellent  for  those 
who  have  a  fair  power  of  self-command.  In  addition 
to  the  output  of  muscular  energy  they  both  bring  into 
play  the  balancing  and  coordinating  faculties,  and 
thus  avert  the  danger  of  irksomeness. 

Hunting. — To  the  neurasthenic  of  trained  mind 
and  innate,  though  perhaj)s  undeveloped,  love  of 
Nature  the  sport  of  hunting  often  opens  up  new  and 
varied  fields  of  activity.  It  sometimes  develops,  for 
one  thing,  an  unsuspected  taste  for  taxidermy,  and 
nearly  always  brings  the  special  senses  of  sight,  hear- 
ing, touch,  and  smell  into  a  high  degree  of  activity. 
The  whole  range  of  advantages  is  so  enticingly  set 
forth  by  a  physician  who  found  nervous  and  mental 
health  in  the  sport,  that  we  are  impelled  to  quote 
parts  of  his  story.  He  says  :  ^  "  Travel  was  tried 
with  some  benefit,  but  I  did  not  get  the  best  results 
of  my  time  till  I  took  to  the  fields  and  forests — '  gun 
in  hand.'  I  never  hunted  and  never  owned  a  gun 
until  I  was  past  fifty.  ...  I  studied  the  habits 
of  birds;  used  all  the  skill  I  could  master  in  my  efforts 
to  get  a  shot,  which  often  requires  a  great  deal  of 
strategy.  .  .  .  The  eye  is  constantly  under  train- 
ing, the  ear  also;  every  footprint  of  Nature,  ever}' 
motion  and  sound  must  be  caught  and  analyzed.  If 
a  nut  falls,  if  leaves  rustle,  or  any  unusual  noise  is 
heard,  an  immediate  investigation  must  be  had,  and 
a  quick  decision  made  as  to  the  cause.  .  .  .  Thus 
led  by  the  eye  and  ear,  the  muscles  of  the  entire  body 
are  called  into  the  most  delightful  activity,  with  the 
least  possible  effort  of  the  will,  nearly  resembling  the 

^Dr.  Holbrook's  Hygiene  of  the  Brain  and  A'eii'es,  p.  198. 


308  THE  BRAIN  AND   NERVOUS  SYSTEM. 

spontaneous  movements  of  childhood.  The  muscles 
seem  to  obey  the  active  senses  with  real  delight  and 
with  much  less  sense  of  fatigue  than  in  any  other  mode 
of  exercise.  .  .  .  The  muscular  system  gains  in 
strength,  blood  is  sent  to  the  extremities  and  to  the 
surface,  the  skin  becomes  active,  the  brain  is  released 
of  its  excess  of  circulation,  the  nervous  system  is  rested, 
the  entire  man  refreshed  and  renewed." 

There  are  still  other  modes  of  outdoor  activity 
which  are  of  undoubted  value  from  a  nervous  and 
mental  standpoint,  but  those  already  mentioned  are 
sufficient  to  illustrate  the  underlying  hygienic  prin- 
ciples involved.  To  state  the  case  briefly,  the  aim  in 
all  muscular  exertion  should  be  toward  conservation 
rather  than  toward  excessive  outpoint  of  nervous 
energy  in  either  its  dynamic  or  its  emotional  form. 
It  is  thus,  and  only  thus,  that  the  organism  can  be 
brought  into  a  condition  which  fits  it  to  succumb  to 
the  regularly-recurring  incidence  of  natural  sleep. 

SLEEP. 

Of  the  reparative  power  of  sleep  and  the  necessity 
of  securing  it  during  the  hours  which  Nature  herself 
unerringly  indicates,  mention  has  already  been  made. 
It  will  be  well,  however,  to  consider  the  subject  in 
greater  detail,  both  in  its  physiologic  and  pathologic 
aspects. 

Physiologic  Considerations. — As  already  stated, 
the  waste-products  of  activity  appear  to  be  the  prime 
cause  of  sleep,  and  on  them  probably  depends  the 
distribution  of  the  blood  which  has  been  observed 
during  this  condition..  To  make  the  blood-supply  to 
the  brain  the  primary  factor  of  importance  in  the 


SLEEP.  309 

production  of  sleep — as  certain  physiologists  have 
attempted — is,  however,  manifestly  illogical,  since 
drowsiness  may  be  present  synchronously  with  un- 
questionable cerebral  congestion  or  the  opposite  ex- 
treme,  cerebral  anemia. 

Under  ordinary  circumstances  normal  sleep  may  be 
said  to  take  place  without  profound  lowering  of 
blood-pressure,  and  it  is  more  than  probable  that  it  is 
due  to  the  benumbing  influence  of  the  waste-products 
of  metabolism  mentioned  above  upon  the  cells  of 
those  areas  of  the  brain-cortex  which  preside  over 
the  senses.  A  strong  proof  of  the  truth  of  this 
hypothesis  is  found  in  the  following  observation  of 
Striimpell,^  recorded  many  years  ago  :  A  young  man 
had  lost  all  power  of  sensation  excepting  through  the 
right  eye  and  the  left  ear.  A  bandage  over  the  eye 
and  a  plug  in  the  ear  effectually  barred  all  communi- 
cation between  his  brain  and  the  outer  world.  At 
the  end  of  two  or  three  minutes  of  ineffectual 
attempt  on  his  part  to  arouse  the  sense  of  hearing  by 
clapping  his  hands,  his  efforts  ceased;  respiration  and 
pulsation  were  deepened  and  retarded,  and  the  re- 
moval of  the  bandage  showed  the  patient  with  his 
eyes  shut  in  genuine  sleep.  Additional  proof  of  the 
correctness  of  the  above  hypothesis  lies  in  the  fact 
that  the  majority  of  persons  who  possess  the  ability 
to  fall  rapidly  asleep  are  individuals  whose  waking 
life  is  almost  entirely  sustained  by  their  external 
perceptions.  For  them  the  production  of  slumber 
simply  entails  the  securing  of  shelter  from  the  sounds 
and  impressions  of  the  air  and  the  shutting  out  of 
other  excitants  by  closing  the  eyes.     After  these  pro- 

iStiumpell,  Dcutsch.  Arch.f.  klin.  Me  J.,  1S64. 


3IO  THE  BRAIN  AND  NERVOUS  SYSTEM. 

cedures  very  little  remains  for  the  production  of 
ordinary  consciousness,  and  sleep  readily  supervenes. 

From  the  experimental  standpoint  also  we  have 
important  evidence  bearing  upon  the  points  under 
consideration.  By  the  aid  of  the  plethysmograph, 
Mosso  ^  was  enabled  to  compare  the  circulation  in  the 
human  brain,  laid  bare  by  erosion  of  the  cranial 
bones,  with  the  movement  of  the  blood  in  other 
organs  of  the  body.  The  occurrence  of  sleep  caused 
a  diminution  in  the  number  of  respirations  and  a  fall 
of  six  or  eight  beats  in  the  pulse.  The  volume  of 
the  brain  and  its  temperature  were  at  the  same  time 
slightly  reduced  through  a  diversion  of  a  portion  of 
the  blood-current  to  other  regions  of  the  body.  If 
during  sleep  a  ray  of  light  was  allowed  to  fall  upon 
the  eyelids,  or  if  any  organ  of  sense  was  moderately 
excited  without  waking  the  patient,  his  respiration 
was  at  once  accelerated,  the  heart  began  to  beat  more 
frequently,  and  the  blood  flowed  more  copiously  into 
the  brain.  Similar  incidents  accompanied  the  act  of 
dreaming.  The  renewal  of  complete  consciousness 
was  followed  by  an  immediate  increase  in  the  activity 
of  the  cerebral  circulation. 

Attempts  have  been  made  to  trace  a  resemblance 
between  certain  of  the  phenomena  of  syncope  and 
sleep,  owing  to  the  fact  that  unconsciousness  is  a 
common  attribute  of  both  conditions;  but  it  is  clearly 
evident  from  the  facts  already  adduced  that  the 
pathologically  bloodless  state  of  the  brain  which 
accompanies  the  former  condition  is  in  nowise  analo- 
gous to  the  much  less   marked   lowering  of  blood- 

*  Mosso,  Ueber  den  Kreislauf  des  Blutes  im  menschlichen  Gehirn,  Leip- 
zig, 1881. 


INSOMNIA.  3  I  I 

pressure  which  accompanies  sleep.  Tlie  attempted 
analogy  between  the  stnpor  of  alcoholic  intoxication 
and  sleep  is  also  highly  illogic,  and  will  receive  fur- 
ther attention  in  the  consideration  of  the  measures 
for  inducing  sleep. 

Insomnia. — From  all  the  evidence  at  command  we 
are  justified  in  believing  that  if  we  can  successfully 
disconnect,  as  it  were,  the  cortical  end-organs  of  the 
senses  from  stimuli  coming  to  them  either  from 
within  or  without  the  organism,  consciousness  will 
be  so  far  abolished  as  to  produce  sleep,  and  this  gives 
us  a  rational  basis  upon  which  to  work  in  the  preven- 
tion of  insomnia. 

Insomnia  is  of  two  orders — functional  and  sympto- 
matic, but  only  the  former  will  be  considered.  This 
occurs  most  commonly  in  neurotic  individuals  and  in 
overtaxed  brain-workers,  and  may  be  complete  or 
partial.  As  previously  stated,  many  neurasthenics 
unintentionally  exaggerate  the  extent  to  which  they 
suffer  from  it.  The  pathologic  basis  of  insomnia  is 
probably  to  be  sought,  in  the  class  of  cases  under 
discussion,  in  a  persistence  of  the  hyperemia,  with 
its  natural  anatomic  and  chemic  consequences,  which 
accompanies  intense  cerebral  activity.  This  sup- 
position is  rendered  all  the  more  tenable  by  the 
recent  discovery  of  Obersteiner^  of  the  presence  on 
even  the  finer  cerebral  vessels  of  nerves  which  di- 
rectly govern  the  blood-supply  to  the  brain.  These 
nerves,  the  discoverer  further  tells  us,  are  easily  ren- 
dered paretic  and  lose  their  power  to  respond  at  a  time 

'  Obeisteiner,  Prof.  H.  "  Die  Innervation  der  Gehirngefasse,"  Jah?-- 
bitch  f.  Psychiatrie  u.  Neurologic,  Band  xvi.  Hefte  i  u.  2,  p.  215  et  seq., 
1897. 


312  THE   BRAIN  AND   NERVOUS  SYSTEM. 

when  those  of  other  organs  of  the  body  respond 
readily.  This  being  so,  the  acceptance  of  the  patho- 
logic view  expressed  is  not  diihcult,  and  it  will  be 
seen  that  the  severity  of  the  insomnia  will  vary  with 
the  extent  to  which  the  cortical  centers  of  the  brain 
are  exposed  to  morbid  activity  through  a  sort  of 
paretic  hyperemia. 

Treatment  of  Insomnia. — For  all  but  the  most 
profound  sufferers  from  insomnia  the  treatment  is 
simple  and  easily  carried  out.  Mental  work  should 
be  performed  during  the  first  part  of  the  day  and 
restricted  to  four  or  six  hours.  The  importance  of 
outdoor  exercise  has  already  been  emphasized.  The 
bed-chamber  should  be  cool  ;  the  bed  hard  and  its 
coverings  light.  A  fairly  long  time  should  be  spent 
in  preparation  for  retiring,  but  care  should  be  taken 
that  the  feet  do  not  become  cold  during  this  time, 
since  the  sensory  stimuli  thus  provoked  may  in  them- 
selves be  sufficient  to  keep  the  cortical  centers  alert 
and  prevent  sleep.  Undue  heat  of  any  part  of  the 
body  surface  may  also  cause  wakefulness  ;  but  for 
certain  people  a  warm  bath  taken  just  before  retiring 
brings  about  the  desired  result.  Those  who  persist 
in  going  over  in  their  minds  the  affairs  of  the  day 
after  their  heads  have  touched  the  pillow  should  at- 
tempt to  divert  brain-activity  by  giving  the  stom- 
ach something  to  work  upon,  such  as  a  glass  of 
warm  milk,  a  cup  of  hot  bouillon,  or  even  a  glass 
of  beer.  Any  large  amount  of  alcohol  should  not, 
however,  be  taken  at  this  time,  since  between  the 
stupor  thus  often  produced  and  the  healthful  restora- 
tion of  energy  which  accompanies  genuine  sleep 
there  can  be  no  rational  comparison.    The  bad  effects 


TKKATMENT  OF  INSOMNIA.  313 

of  strong  coflee  taken  at  night  need  hardly  be  men- 
tioned. 

Prolonged  insomnia,  if  it  be  absolute,  is  a  very 
dangerous  condition,  and  the  measures  necessary  to 
overcome  it  are  consequently  more  active.  Tlie 
patient — for  the  victim  of  continued  insomnia  must 
be  regarded  as  a  sick  man  or  woman — .should  be  kept 
in  bed,  and  opium  and  its  derivatives,  as  well  as  the 
whole  group  of  so-called  hypnotics,  should  be  sedu- 
lously excluded.  The  mere  application  of  mustard- 
leaves  over  the  upper  part  of  the  chest  and  back  for 
long-continued  periods  will  frequently  relieve  uneasy 
feelings  in  the  head  and  produce  sleep  for  several 
hours.  In  using  this  remedy  care  should  be  taken 
not  to  blister  the  skin,  since  blistering  is  an  unneces- 
sarily severe  measure.  Counter-irritation,  which  is, 
of  course,  the  object  of  the  treatment  just  advocated, 
may  also  be  secured  by  the  application  of  bottles  of 
warm  water  applied  to  the  feet  and  back,  and  by  the 
use  of  warm  compresses  over  the  abdomen.  Very 
gentle  shampooing  or  "massage"  applied  to  the 
head  and  neck  four  or  five  times  a  day  for  a  few  min- 
utes at  a  time  is  generally  soothing.  This  should 
be  done  by  the  spread-out  fingers,  starting  from  the 
sides  and  back  of  the  head,  and  being  carried  gently 
down  to  the  clavicles  and  about  the  root  of  the  neck. 
One  of  the  best  methods  of  depleting  the  blood- 
vessels of  the  brain  is  to  draw  the  blood  into  the 
vessels  of  the  abdomen  by  means  of  food.  Food 
should,  therefore,  be  given  in  small  amounts  at  fre- 
quent intervals,  and  the  largest  meal  should  come  at 
night.  Gentle  rubbins;  of  the  whole  bodv,  beQ-inning 
with  the  lower  extremities  and  working  up,  is  a  good 


314  THE  BRAIN  AND  NERVOUS  SYSTEM. 

method  of  eliminating  waste-products  from  the 
tissues,  but  should  not  be  done  after  six  in  the  even- 
ing and  never  longer  than  five  or  six  minutes  at  any 
time.  If  carried  out  after  the  hour  indicated  or  for 
a  longer  time  than  five  or  six  minutes,  the  rubbing  is 
likely  to  excite  the  patient  and  thus  defeat  the  pur- 
pose for  which  it  is  undertaken.  In  any  case  the 
danger  of  producing  excitement  is  lessened  by  the 
use  of  oil  on  the  operator's  hands.  Such  advice  may 
be  contrary  to  the  laws  which  govern  the  technic  of 
massage;  it  is,  however,  not  massage  but  gentle 
rubbing  that  is  indicated  in  prolonged  insomnia. 
If  these  measures  are  faithfully  carried  out,  the  re- 
sort to  sedatives  and  hypnotic  drugs  rarely  becomes 
necessary,  and  the  danger  of  the  formation  of  vicious 
drug-habits  is  happily  averted. 

Conclusion. — In  closing,  it  is  reiterated  that  affec- 
tions of  the  brain  and  nervous  system  are  in  greater 
measure  preventable  than  those  of  other  parts;  conse- 
quently the  mental  and  nervous  salvation  of  the 
individual  is,  practically  speaking,  to  a  very  marked 
extent  within  his  own  hands,  and  may  be  worked  out 
by  him  through  rigid  attention  to  the  guidance  of 
hygienic  laws. 


PHYSICAL  EXERCISE. 

By  G.  N.  STEWART,  M.  D.  (Edin.), 

OF   CHICAGO, 

Professor  of  Physiology  in  the  University  of  Chicago. 


PHYSIOLOGY  OF  MUSCULAR  MOVEMENT. 

Spontaneous  movement  is  the  sign  of  life  which 
appears  the  most  typical  and  the  most  decisive  to  the 
popular  mind.  Nor  is  this  instinct  deceptive.  For, 
although  in  the  narrow,  technical,  and  strictly  scien- 
tific sense,  life  may  exist  without  visible  spontaneous 
movement,  this  is  only  possible  for  any  considerable 
time  in  plants  and  in  certain  specialized  animal 
cells:  the  blossom  or  the  bacillus  may  live  without 
moving,  but  not  the  bird;  the  liver-cell  and  perhaps 
the  nerve-cell,  but  not  the  man. 

The  Muscles. — All  the  movements  that  are  so 
characteristic  of  animal  life — not  only  the  voluntary 
movements,  but  the  involuntary  movements  of  the 
heart,  the  stomach,  the  intestines,  the  iris,  and  other 
organs — are  carried  out  by  muscles,  which  make  up 
nearly  one-half  of  the  weight  of  the  body  of  a  man, 
and  a  somewhat  smaller  proportion  of  the  body  of  a 
child.  The  voluntary  muscles — such  as  the  biceps, 
which  forms  the  rounded,  fleshy  mass  on  the  front  of 
the  upper  arm,  and  the  gastrocnemius  in  the  calf  of 
the  leg — are  connected,  usually  by  cords  or  bands  of 

315 


3l6  MUSCULAR   MOVEMENT. 

dense  fibrous  tissue,  called  tendons,  to  the  bones,  and 
hence  are  also  called  the  skeletal  muscles.  They 
consist  of  long,  cylindric  fibers  varying  somewhat  in 
length  and  breadth,  but  on  the  average  about  5^  inch 
in  diameter,  and  an  inch  or  even  two  or  three  inches 
long-.  The  fibers  are  marked  with  alternate  dark  and 
light  stripes,  which  run  across  their  length,  and  from 
this  appearance  the  skeletal  muscles  are  termed 
striped  or  striated  muscles.  Each  fiber  is  made 
up  of  a  number  of  fine  longitudinal  fibrils  arranged 
side  by  side,  with  a  material  of  a  different  nature 
between  them,  the  whole  being  inclosed  in  a  thin 
sheath,  called  the  sarcolemma.  The  fibers  are  united  by 
connective  tissue  into  small  bundles,  and  these  again 
into  larger  bundles,  a  number  of  which  constitute 
what  we  call  a  muscle.  In  the  connective  tissue 
run  the  blood-vessels  of  the  muscles.  The  capillaries, 
or  smallest  vessels,  run  close  to  the  sarcolemma,  but 
no  vessel  actually  enters  any  fiber.  The  muscular 
fibers  of  the  stomach,  intestines,  blood-vessels,  etc., 
are  much  shorter  and  thinner  than  the  striated  fibers, 
and,  having  no  transverse  stripes,  are  spoken  of  as 
unstriped  or  smooth  muscular  fibers.  The  fibers 
of  the  heart  occupy  an  intermediate  position  between 
the  smooth  and  the  striated  muscular  fibers.  Like 
the  latter  they  are  transversely  striped,  but  like  the 
former  they  are  not,  in  most  individuals,  under  the 
control  of  the  will. 

Muscular  Contraction. — The  characteristic  phys- 
iologic property  of  muscular  fibers  is  that  when  stim- 
ulated they  respond  by  a  shortening  or  contraction 
without  any  change  of  volume.  In  this  way  the 
ends  of  the  stimulated  muscles  come  closer  to  each 


MUSCULAR   CONTRACTION.  317 

other,  and  if  they  are  attached  to  bones  these  are 
made  to  execute  movements,  the  direction,  extent, 
and  force  of  which  depend  on  the  direction  of  the 
pull  of  the  muscle,  the  nature  of  the  joint  in  which 
the  movement  takes  place,  the  size  of  the  muscle,  and 
the  degree  of  intensity  of  its  excitation. 

The  contraction  of  muscle  may  be  brought  about 
artificially  by  stimulating  the  fibers  directly,  as  by 
striking  or  pinching  them,  or  by  sending  electric 
currents  through  them,  or  by  suddenly  heating  or 
cooling  them,  or  by  putting  into  contact  with  them 
some  chemic  substance,  such  as  common  salt.  All 
these  forms  of  stimulation  can  be  easily  illustrated 
on  the  excised  muscles  of  a  frog.  In  the  living  body 
muscles  are  generally  excited  through  the  nervous 
system.  In  such  a  muscle  as  the  biceps  every  mus- 
cular fiber  is  supplied  with  at  least  one  branch  of  a 
nerve-fiber.  The  nerve-fibers  are  long  branches,  or 
'processes,  of  nerve-cells  situated  in  the  gray  matter 
of  the  spinal  cord.  These  nerve-cells,  again,  are  in 
close  contact  with  other  nerve-fibers  running  down 
from  nerve-cells  situated  in  the  gray  matter  of  the 
brain.  When  the  biceps  muscle  is  voluntarily  con- 
tracted, "something"  which  we  call  a  nerve-impulse, 
some  change  in  the  condition  of  the  nerve,  sweeps 
down  from  a  definite  region  of  the  gray  matter  of  the 
brain  along  certain  nerve-fibers  to  certain  nerve-cells 
in  the  upper  portion  of  the  cord,  and,  modified,  per- 
haps, in  these  nerve-cells,  is  thence  transmitted  by 
the  motor  nerve-fibers  to  the  muscle.  What  this 
"something"  is  we  do  not  know,  but  it  is  probably 
a  chemic  change,  which  we  may  imagine  running 
along  the  nerye  with  a  speed  somewhat  greater  than 


3l8  PHYSICAL   EXERCISE. 

that  of  the  fastest  train  in  the  world,  and  involving 
portion  after  portion  of  it,  as  an  explosion  runs  along 
a  train  of  gunpowder  to  one  end  of  which  a  lighted 
match  has  been  applied.  When  the  nerve-impulse 
reaches  the  muscular  fibers,  it  sets  up  in  them 
changes  of  a  different  and  much  more  energetic 
character,  the  external  token  of  which  is  contraction. 
We  must,  therefore,  regard  the  muscle-fiber,  the 
nerve-fiber,  and  the  nerve-cell  as  a  single  machine  or 
as  successive  links  in  a  chain.  If  one  link  gives  way, 
the  chain  is  broken;  if  something  goes  wrong  with 
one  part  of  the  machine,  the  whole  is  thrown  out  of 
gear.  For  instance,  if  the  nerve  is  divided  or  crushed 
at  any  point  between  the  muscle  and  the  spinal 
nerve-cells  from  which  its  fibers  come,  or  the  spinal 
nerve-cells  are  destroyed  by  disease,  the  muscle  is  not 
only  paralyzed  immediately,  but  in  a  short  time 
wastes  away  and  becomes  little  more  than  a  mass 
of  connective  tissue.  In  like  manner,  although  the 
process  takes  a  longer  time,  removal  or  permanent 
disuse  of  a  muscle  or  group  of  muscles,  as  after 
amputation  of  a  limb,  particularly  in  young  persons, 
leads  first  to  enfeeblement  and  then  to  actual  decay 
or  degeneration  of  the  nerve-cells  in  the  spinal  cord 
which  are  connected  with  it.  In  course  of  time  even 
the  corresponding  group  of  nerve-cells  in  the  brain 
may  show  unmistakable  signs  of  wasting  or  atrophy. 
It  is,  on  the  other  hand,  exceedingly  probable — and 
this  is  one  of  the  most  important  points  in  the 
physiology  of  rational  physical  training — that  in- 
creased use  of  a  group  of  muscles,  especially  during 
the  period  of  growth,  leads  to  an  increase  in  the  size 
and  efficiency  of  the  nerve-cells  of  the  spinal  cord 


AUTOMATIC  MOVEMENTS.  3I9 

and  brain  which  are  connected  with  them,  as  it  is 
known  to  do  in  the  case  of  the  muscles  themselves. 

Voluntary,  Automatic,  and  Reflex  Movements. 
— Most  of  our  ordinary  movements,  and  particularly 
those  by  means  of  which  we  act  on  our  environment 
and  adjust  our  relations  to  it,  are  brought  about  by  a 
distinct  act  of  the  will.  But  certain  nerve-cells  con- 
nected even  with  striated  muscles  may  discharge  im- 
pulses that  lead  to  automatic  contraction  of  these 
muscles  without  voluntary  effort  and  even  in  the 
absence  of  consciousness.  Such  are  the  nerve-cells 
which  preside  over  the  muscles  used  in  ordinary  res- 
piration, the  chief  of  which  are  the  diaphragm  sepa- 
rating the  chest  from  the  abdomen  and  certain  muscles 
that  elevate  the  ribs.  Although  we  may,  and  often  do, 
voluntarily  alter  the  rate  or  the  depth  of  our  breath- 
ing, yet  in  general  we  do  not  think  at  all  about  it, 
and  in  sleep,  of  course,  it  goes  on  entirely  without 
our  knowledge.  The  impulses  that  set  the  respira- 
tory muscles  into  action  are  discharged  from  a  nerve- 
center  or  collection  of  nerve-cells  in  the  medulla 
oblongata,  a  portion  of  the  central  nervous  system 
which  serves  to  join  the  spinal  cord  to  the  brain. 
Although  the  rate  and  intensity  of  its  discharge  are 
regulated  by  nerve-impulses  carried  to  it  by  afferent, 
or  sensory,  nerves  from  the  lungs  and  other  organs, 
this  respiratory  center  seems  capable,  even  in  the 
absence  of  such  impulses,  of  sending  out  impulses 
along  the  efferent,  or  motor,  nerves  to  the  respiratory 
muscles.  It  is,  therefore,  spoken  of  as  an  automatic 
center,  and  the  respiratory  movements  may  be  con- 
sidered in  part  automatic  movements.  But  the  most 
typical  examples  of  automatically  contracting  organs 


320  PHYSICAL  EXERCISE. 

are  the  heart  and  the  digestive  canal,  whose  move- 
ments are  entirely  beyond  the  control  of  the  will,  ex- 
cept that  in  a  few  individuals  an  increase  in  the  rate 
of  the  heart  can  be  voluntarily  produced  and  main- 
tained for  a  short  time. 

A  third  group  of  movements  embraces  what  are 
called  reflex  movements.  Typical  reflex  move- 
ments are  the  winking  of  the  eyelids  when  the  eye- 
ball is  touched,  and  the  drawing  up  of  the  foot  when 
the  sole  is  tickled.  Everyone  knows  that  both  are 
quite  involuntary.  The  nerve-impulses  which  cause 
the  contraction  of  the  muscles  concerned  are  dis- 
charged by  certain  groups  of  nerve-cells  constituting 
the  reflex  centers  for  these  movements,  situated  in 
the  case  of  the  eyelid-reflex  in  the  brain  and  in  the 
case  of  the  foot  or  plantar  reflex  in  the  lower  portion 
of  the  spinal  cord.  The  discharge  is  brought  about 
by  the  arrival  in  the  reflex  centers  of  afferent  im- 
pulses set  up  in  the  sensory  nerves  of  the  eyeball  or 
the  sole  by  the  contact  or  the  tickling.  It  is  not 
necessary  for  the  discharge  of  a  typical  reflex  move- 
ment that  the  person  should  be  conscious  of  the 
stimulus  which  gives  rise  to  the  reflex,  or  should 
experience  any  sensation  from  it.  Many  reflex  move- 
ments can  be  elicited  during  sleep. 

Work  Done  by  Muscular  Contraction. — A  muscle 
is  essentially  a  machine  for  doing  work,  but  in  the 
scientific  sense  the  term  work  does  not  involve 
precisely  the  same  idea  as  in  the  economic  or  the 
everyday  sense;  the  former  is  wider  than  the  latter. 
Thus,  when  a  man  lifts  a  weight  against  the  force  of 
gravity  he  does  work  in  the  scientific  sense,  whether 
the  weight   be   a   sack   of  coal,    a    book,    the   pros- 


TRANSFORMATION  OF  TOOD-SUBSIANCES.        32 1 

trate  form  of  an  opponent  on  the  football -field,  or 
his  own  body  as  he  ascends  a  ladder  or  a  hill.  The 
amount  of  the  work  done  by  a  contracting  muscle  is 
measured  in  terms  of  the  weight  which  it  raises  and 
the  height  to  which  the  weight  is  raised.  For  in- 
stance, if  a  muscle  raises  a  weight  of  a  pound  to  the 
height  of  a  foot,  it  is  said  to  have  done  one  fo9t- 
pound  of  work;  if  it  raises  two  pounds  to  the  height 
of  a  foot  or  one  pound  to  the  height  of  two  feet,  the 
work  done  is  two  foot-pounds,  and  so  on. 

Transformation  of  Food-substances  into  Mus- 
cular Energy. — No  work  can  be  done  without  using 
up,  or  rather  transforming,  an  equivalent  amount  of 
energy.  Thus,  a  steam-engine  transforms  into  work 
a  portion  of  the  energy  stored  up  millions  of  years 
ago  by  the  sun's  rays  in  the  primeval  vegetation  and 
set  free  in  the  burning  of  the  coal.  In  like  manner,  a 
contracting  muscle  changes  into  work  a  portion  of  the 
energy  stored  up  (again  directly  or  indirectly  by  the 
sun's  rays)  in  the  food-substances,  which  are  oxidized, 
that  is  to  say,  burned  at  a  comparatively  low  tem- 
perature, in  its  fibers.  The  "  burning"  of  food-sub- 
stances in  the  muscle  is  essentially  the  same  process 
as  the  burning  of  coal  in  the  furnace  of  the  engine, 
only  in  the  muscle  the  oxidation  takes  place  by  some 
peculiar  agency  not  at  present  thoroughly  understood 
at  a  temperature  of  less  than  100°  Fahrenheit,  while 
for  the  combustion  of  coal  or  of  food-substances  in  a 
furnace  a  temperature  of  several  hundreds  of  degrees 
is  required.  The  products  formed  are,  however,  prac- 
tically the  same  whether  the  food  is  slowly  burned  in 
the  muscles  and  other  tissues  of  the  body  or  rapidly 
burned  in  the  fire,  the  only  essential  difference  being 
21 


322  Physical  exercise.. 

that  in  the  body  the  combustion  of  the  nitrogenous 
substances,  such  as  white  of  ^^%  or  lean  meat,  is  not 
quite  so  complete  as  it  would  be  in  a  furnace,  the 
nitrogen  being  given  off  in  the  form  of  urea,  which 
can  itself  be  further  oxidized  to  nitrogen  gas,  carbonic 
acid,  and  water.  Fat,  starch,  and  sugar  are  fully 
burned  in  the  body,  the  end-products  being  water 
and  carbonic  acid. 

As  regards  the  proportion  of  the  total  energy  of 
the  food  which  can  be  converted  into  work,  the 
muscles  are  more  economical  than  any  machine  yet 
constructed  by  man,  since  they  can,  under  favorable 
conditions,  do  work  equivalent  to  one-fourth  or  even 
one-third  of  the  energy  of  the  food-substances  con- 
sumed in  them,  a  proportion  far  in  excess  of  the 
efficiency  of  the  best  steam-engines. 

The  most  important  of  the  food-substances 
used  up  in  a  contracting  muscle  is  a  sugar  called 
glucose,  or  grape-sugar,  which  is  formed  in  the  body 
in  digestion  from  starch  and  from  ordinary  cane- 
sugar,  but  also  occurs  in  plants  and  can  be  produced 
artificially  by  heating  cane-sugar  with  dilute  acids. 
Another  substance  of  importance  is  glycogen,  some- 
times called  animal  starch.  It  is  formed  in  the  body 
from  glucose  and  other  substances,  and  is  always 
present  in  normal  muscles,  although  it  diminishes 
in  amount,  and  may  even  disappear  altogether,  when 
the  muscles  are  strongly  stimulated  for  a  long  time, 
as  when  spasms  are  produced  in  an  animal  by  poison- 
ing it  with  strychnin.  A  certain  amount  of  fat  is 
also  invariably  present  in  muscles,  and  may  be  used 
up  during  their  contraction. 

The  nitrogenous  substances  of  the  muscle  do  not 


THE  EFFECTS   OF  MUSCULAR  EXERCISE.         323 

appear,  under  ordinary  circumstances,  to  furnish  any 
large  portion  of  the  energy  of  the  contraction,  for  mus- 
cular exercise,  unless  it  is  severe  and  prolonged,  causes 
hardly  any  increase  in  the  amount  of  such  substances 
consumed,  as  indicated  by  the  amount  of  urea  excreted. 
On  the  other  hand,  exercise  causes  a  marked  increase 
in  the  quantity  of  carbonic  acid  eliminated  by  the 
lungs  ;  and  we  have  already  recognized  carbonic  acid 
as  the  form  in  which  the  carbon  of  fats,  sugars,  and 
starchy  substances  leaves  the  body.  When,  however, 
the  food  consists  mainly  of  lean  meat,  which  contains 
little  but  nitrogenous  food-substances,  these  are  util- 
ized by  the  muscles  in  contraction  instead  of  the  car- 
bonaceous sugar  and  fat,  which,  so  to  say,  they  select 
when  a  choice  is  offered  them.  Under  all  circum- 
stances a  certain  amount  of  nitrogenous  or  proteid 
food  is  required  by  the  muscular  tissue,  for,  as  in  all 
cells,  the  real,  living  framework  of  the  muscle-fiber 
contains  proteid  substances  as  its  essential  constitu- 
ents. We  may,  in  fact,  conceive  of  the  fat  and  the 
sugar  as  bearing  the  same  relation  to  the  proper  sub- 
stance of  the  muscle  as  the  water  in  the  boiler  and  the 
coal  in  the  furnace  to  the  steam-engine — necessary 
for  its  work,  yet  perfectly  distinct  from  it. 

THE    EFFECTS    OF    MUSCULAR    EXERCISE. 

Fatigue  of  Muscle. — It  is  a  familiar  fact  that  when 
the  muscles  are  caused  to  work  hard  for  a  certain  time 
they  become  fatigued.  The  process  of  fatigue  can  be 
best  studied  when  a  muscle — for  example,  one  of  the 
muscles  on  the  front  of  the  forearm  which  by  their 
contraction  flex  or  bend  the  fingers  toward  the  palm — 
is  made  repeatedly  to  lift  a  weight   attached   by  a 


324  PHYSICAL   EXERCISE. 

leather  collar  to  a  joint  of  one  of  the  fingers,  the  hand 
and  arm  being  fastened  so  that  none  of  the  other  mus- 
cles can  assist.  The  number  of  contractions  and  the 
height  to  which  the  weight  is  raised  by  each  are  reg- 
istered on  a  revolving  drum,  and  the  whole  arrange- 
ment is  called  an  ergograph.  If  the  muscle  is  made 
to  contract  strongly  and  continuously,  as  when  a 
heavy  weight  is  held  up  by  the  finger,  it  rapidly 
becomes  fatigued  and  soon  the  weight  drops.  But 
if  each  contraction  is  a  short  one,  and  is  succeeded  by 
an  interval  of  rest,  and  if  the  weight  is  not  too  great, 
the  muscle  may  go  on  raising  the  weight  for  a  consid- 
erable time.  Thus  in  an  experiment  of  Lombard's 
one  of  the  muscles  of  the  hand  lifted  a  light 
weight  once  every  second  for  two  hours  and  a  half, 
or  9000  times  in  all,  without  showing  any  fatigue. 
An  increase  in  the  weight  or  an  increase  in  the  rate 
of  contraction  was  quickly  followed  by  fatigue  of  the 
muscle.  Ultimately  when  the  person  has  repeatedly 
raised  a  considerable  weight  with  all  the  force  which 
the  muscle  can  exert,  the  time  comes  when  a  rapid 
decrease  in  the  height  of  the  contraction  can  be  noticed, 
and  sooner  or  later  the  efibrt  to  raise  the  weight  fails. 
If  the  person  still  strives  to  raise  the  weight,  a  partial 
recovery  of  power  takes  place,  after  which  the  muscle 
again  speedily  becomes  fatigued,  and  soon  refuses  once 
more  to  raise  the  weight.  There  is  every  reason  to 
believe  that  when  a  muscle  is  fatigued  by  voluntary 
contraction  the  fatigue  involves  not  only,  nor  at  first 
chiefly,  the  muscular  fibers  themselves,  but  also  the 
nerve-cells  in  the  brain  or  cord.  In  fact,  when  the  fa- 
tigue is  pushed  so  far  that  it  is  no  longer  possible  by  a 
voluntary  effort  to  caiise  the  finger  to  lift  the  weight, 


REtiTORATIVE   rKOPERllES   OE  EOOD.  325 

it  is  the  nerve-cells,  and  not  the  nniscular  filjcrs,  which 
first  give  ont.  For  at  this  moment  direct  stimulation 
of  the  muscle  by  an  electric  current  will  generally 
cause  it  to  contract  and  raise  the  weight. 

So  far  as  the  fatigue-process  involves  the  muscle,  it 
seems  to  be  due  to  two  things  :  the  using  up  of  the 
material  necessary  for  contraction  and  the  accumula- 
tion in  the  muscle  of  waste  substances  produced  by  the 
active  muscle,  for  example  an  acid  called  sarcolactic 
acid,  which  resembles  the  acid  formed  in  milk  when  it 
turns  sour. 

The  restorative  properties  of  food-substances  in 
fatigue  of  muscle  show  conclusively  that  these  mate- 
rials are  consumed  in  muscular  contraction.  The  tak- 
ing of  a  small  amount  of  sugar,  for  instance,  has  been 
found  markedly  to  lessen  the  fatigue  and  increase  the 
endurance  of  soldiers  tired  out  by  long  marches,  and  we 
have  already  seen  that  of  all  the  food-substances  in 
muscle,  sugar  appears  to  be  the  most  important  for  the 
contraction.  The  fact  that  it  is  rapidly  absorbed  from 
the  digestive  tube  also  accounts  in  part  for  its  restora- 
tive effect.  Some  enthusiasts  have  spoken  of  the 
almost  magic  change  produced  by  the  eating  of  a 
handful  of  granulated  sugar.  But  it  must  not  be  sup- 
posed that  the  action  is  a  specific  one.  Sugar  may 
act  most  quickly  in  restoring  fatigued  muscles,  but 
otherfood-substanceshave asimilarefFect;  forinstance, 
fats  (especially  when  taken  in  the  form  of  soups  along 
with  certain  of  the  constituents  of  meat-extract),  and 
the  proteid  substances  contained  in  eggs  and  in  lean 
meat.  Caffein,  the  active  principle  of  coffee,  also 
causes  for  a  time  a  marked  increase  in  the  capacity 
of  a  fatisrned  muscle  to  do  work  as  measured  bv  the 


326  PHYSICAL   EXERCISE. 

ergograph.  Small  quantities  of  alcohol  appear  to 
have  a  similar  effect;  but  in  larger  doses  alcohol 
depresses  the  muscular  power.  And  it  seems  now  to 
be  well  established  that  in  severe  and  continuous  ex- 
ertion, coupled  with  exposure  to  all  weathers,  as  in 
war  and  in  exploriug-expeditions,  tea,  coffee,  and 
cocoa  are  much  more  suitable  stimulants  than  alco- 
hol, although  it  ought  not  to  be  lost  sight  of  that  all 
of  these  things  may  be  taken  in  excess.  Trainers, 
also,  as  a  rule,  allow  their  men  no  spirits,  and  only 
very  moderate  quantities,  if  any,  of  wine  or  beer. 

That  in  addition  to  the  using  up  of  the  substances 
necessary  to  contraction,  the  production  of  waste- 
substances  more  quickly  than  they  can  be  removed 
is  responsible  for  the  onset  of  fatigue,  is  indicated  by 
the  fact  that  the  blood  of  a  dog  completely  tired  out 
by  running,  when  injected  into  the  veins  of  a  per- 
fectly rested  dog,  has  been  seen  to  produce  in  the  latter 
all  the  symptoms  of  fatigue,  which  was  not  the  case 
when  the  blood  of  a  rested  dog  was  injected.  Further, 
the  marked  effect  of  massage  of  the  muscles  in  remov- 
ing the  effects  of  fatigue  would  seem  to  show  that  the 
passage  of  the  excess  of  waste-products  from  the  mus- 
cular fibers  into  the  blood  and  lymph  is  favored  by  the 
kneading  of  the  muscles,  which  increases  the  flow  of 
these  liquids  through  the  muscular  blood-vessels  and 
lymphatics. 

Within  certain  limits  the  same  effect  on  the  flow 
of  blood  through  the  vessels  of  the  muscles  is 
physiologically  produced  during  contraction,  a  very 
beautiful  provision  for  giving  the  active  muscle  that 
increased  supply  of  nutriment  which  it  requires,  and 
for  carrying  off  at  the  same  time  the  excess  of  waste- 


THE   El'FECr  OF  EXERCISE    ON   THE  HEART.    327 

substances  which  it  produces.  This  is  brought  about 
in  two  ways:  by  the  widening  of  the  small  arteries, 
and  therefore  of  the  capillaries,  of  the  muscle,  through 
the  action  of  certain  nerve-fibers'  which  govern  the 
caliber  of  the  arteries,  and  at  the  beginning  of  the 
contraction  by  the  pressure  of  the  thickened  muscle- 
fibers  on  the  veins  that  carry  the  blood  away  from 
the  muscles.  These  veins,  like  most  others,  are  pro- 
vided with  valves  in  their  interior  which  only  permit 
the  blood  in  them  to  flow  out  of  the  muscles  and 
toward  the  heart,  but  not  back  to  the  muscles.  When 
the  veins  are  pressed  on  the  flow  in  the  former  direc- 
tion is  increased.  It  has  been  actually  observed  that 
the  quantity  of  blood  flowing  through  one  of  the 
muscles  used  by  the  horse  in  feeding  was  three  times 
as  great  when  the  animal  was  engaged  in  chewing 
oats  as  when  the  muscle  was  at  rest.  This  is  one  of 
the  local  effects  of  exercise,  and  doubtless  the  increased 
supply  of  nutriment  thus  obtained  is  connected  with 
the  growth  of  muscles  that  are  freely  exercised,  and 
which  is  so  strikingly  displayed  in  the  "brawny 
arms"  of  the  blacksmith  and  the  general  muscular 
development  of  the  professional  pugilist  or  acrobat. 

There  are  also  certain  general  effects  of  exercise 
which  are  of  equal  physiologic  interest  and  hygienic 
importance. 

The  Effect  of  Exercise  on  the  Heart. — It  is  well 
known  that  even  a  moderate  amount  of  exercise 
causes  the  heart  to  beat  more  quickly.  Thus  in  74 
healthy  men  it  was  found  that  running  once  or  twice 

^  These  are  called  vaso-motor  fibers.  They  act  on  the  blood-vessels  by 
increasing  or  diminishing  the  degree  of  contraction  of  the  smooth  muscu- 
lar fibers  in  their  walls. 


328  PHYSICAL   EXERCISE. 

Up  and  down  two  or  three  flights  of  stairs  caused  an 
average  increase  of  32  pulse-beats  per  minute,  or  not 
very  far  from  50  per  cent,  of  the  normal  pulse-rate  at 
rest,  which  is  about  73  in  the  minute  in  the  sitting 
posture  and  about  80  in  the  standing.  The  increase, 
however,  was  very  different  in  different  individuals, 
one  man  having  a  pulse-rate  immediately  after  the 
exercise  of  164  and  another  only  75.  Unless  the 
amount  of  exercise  is  excessive,  although  the  heart 
beats  fast,  there  is'  a  steady,  regular  rhythm,  so 
that  the  right  ventricle  sends  more  blood  through 
the  vessels  of  the  lungs  and  the  left  ventricle  more 
blood  through  the  rest  of  the  body  than  is  the  case 
when  the  person  is  at  rest.  The  increase  in  the  flow 
of  blood  through  the  lungs  permits  more  oxygen  to 
be  taken  into  the  blood  and  more  carbonic  acid  to  be 
excreted,  and  both  of  these  circumstances  are  favor- 
able to  the  actively  contracting  muscles,  which  use 
up  far  more  oxygen  and  produce  far  more  carbonic 
acid  than  muscles  in  repose.  We,  therefore,  see  that 
the  quickly  yet  strongly  beating  heart  is  the  ready 
helpmeet  of  the  hard-worked  and  hungry  muscles 
with  their  rapidly  accumulating  waste  products  and 
their  dilated  blood-vessels. 

The  Effect  of  Exercise  on  Respiration. — In  order 
that  the  increased  amount  of  oxygen  may  be  easily 
obtained  by  the  blood  as  it  passes  through  the  lungs, 
and  the  increased  amount  of  carbonic  acid  contained 
in  it  easily  discharged,  more  air  must  be  taken  into 
and  breathed  out  of  the  lungs,  and  the  respiratory 
movements  are  accordingly  quickened  during  exercise 
as  well  as  the  heart.  This  acceleration  of  the  breath- 
ing is  brought  about  partly  by  the  stimulation  of  the 


PHYSICAL    TRAINING.  329 

sensory,  or  afferent,  nerves  of  the  active  muscles, 
which  carry  impulses  up  to  the  respiratory  center, 
and  partly  by  the  direct  effect  of  the  carbonic  acid, 
and  perhaps  other  substances  produced  by  the  muscle, 
on  the  respiratory  center  as  they  are  borne  through  it 
in  the  current  of  the  circulating  blood. 

The  Effect  of  Exercise  on  the  Skin. — Another 
general  effect  of  exercise  is  the  reddening  of  the  skin 
owing  to  the  dilatation  of  its  blood-vessels,  and  the 
increased  excretion  of  sweat  from  its  glands.  The 
effect  of  the  increased  blood-flow  through  the  cutane- 
ous vessels  is  to  heat  the  skin  itself,  but  to  cool  the 
body,  since  more  heat  is  given  off  from  a  warm  sur- 
face than  from  a  cold  one.  The  evaporation  of  the 
water  of  the  sweat  has  the  same  effect.  In  both  of 
these  ways,  as  well  as  by  means  of  the  increased 
ventilation  of  the  lungs,  the  excess  of  heat  produced 
by  the  active  muscles  is  eliminated,  and  the  tempera- 
ture of  the  blood,  even  during  the  most  intense 
physical  exertion,  seldom  rises  much  more  than  a 
degree. 

The  effect  of  exercise  on  the  digestive  system, 
when  it  is  regular  and  not  immoderate  in  amount,  is 
favorable.  The  appetite  is  increased;  food  is  not  only 
taken  in  larger  quantity,  but  it  is  better  relished, 
more  fully  and  rapidly  absorbed  from  the  stomach 
and  intestine,  and  more  completely  oxidized  in  the 
tissues. 

PHYSICAL  TRAINING. 

Association  with  Mental  Training. — The  saying 
of  Montaigne,  which  is  sometimes  quoted  as  a  watch- 
word by  the  advocates  of  physical  culture,  that  "  we 
have  not  to  train  up  a  soul  nor  yet  a  body,  but  a  man, 


330  PHYSICAL   EXERCISE. 

and  we  cannot  divide  him,"  expresses  a  truth  which 
lies  at  the  basis  of  rational  education.  It  is,  indeed, 
the  strongest  plea  for  systematic  training  of  the  body 
that  it  helps  in  the  harmonious  development  of  the 
whole  man.  Reference  has  already  been  made  to  the 
effects  of  exercise  of  the  muscles  on  the  nerve-cells 
connected  with  them  in  the  spinal  cord  and  brain. 
We  have  seen  how  near  together  in  the  bundle  of  life 
lie  the  muscular  fiber,  the  nerve-fiber  and  the  motor 
nerve-cell.  So-called  muscular  fatigue  we  have 
recognized  as  in  part  fatigue  of  the  nerve-cell.  It  is 
equally  true  that  so-called  muscular  training  is  at  the 
same  time  a  training  of  the  nervous  centers,  and  that 
what  in  ordinary  speech  we  term  muscular  agility  is 
but  the  outward  expression  of  a  nervous  agility,  a 
readiness  of  reception  of  incoming  impressions  and  a 
promptness  of  discharge  of  efferent  impulses  on  the 
part  of  certain  individual  nerve-cells  and  groups  of 
nerve-cells,  extensively  connected  with  each  other 
and  drilled  to  act  in  concert. 

There  is  also  good  reason  to  believe  that  the  effects 
of  muscular  training  are  not  confined  to  the  motor 
centers,  but  that  they  extend  to  other  portions  of  the 
brain  as  well,  even  to  those  portions  which  are  espe- 
cially related  to  mental  processes.  It  has,  for  instance, 
been  clearly  shown  that  many  of  our  ideas,  and  some 
of  them  apparently  the  most  abstract,  are  dependent 
for  their  completeness  and  vividness  on  the  memory 
of  muscular  movements.  To  take  an  example  cited 
by  Sir  James  Crichton-Browne,  when  we  think  of  a 
circle  we  involuntarily  repeat  in  memory,  although 
not  usually  with  our  muscles,  the  movements  of  the 
hand  necessary  to  draw  a  circle  or  the  circular  sweep 


KIND    OF  EXERCISE   MOST  ADVANTAGEOUS.     33 1 

of  the  eyes  necessary  to  view  it.  This,  it  is  true,  is 
not  everything  which  is  involved  in  our  idea  of  a 
circle,  but  it  appears  to  form  an  essential  element  in 
it.  It  is,  indeed,  not  too  much  to  say  that  the  educa- 
tion of  the  nervous  centers  which  have  to  do  with 
the  perception  of  ideas  and  with  intellectual  opera- 
tions would  be  extremely  incomplete  in  the  absence 
of  education  of  the  centers  connected  with  muscular 
movements.  The  distinguished  writer  on  mental 
diseases,  whom  we  have  just  quoted,  goes  so  far  as  to 
speculate  upon  the  possibility  that  "  swaddling-bands 
so  applied  at  birth  as  to  restrain  all  muscular  move- 
ments, and  kept  on  during  infancy  and  childhood, 
would  result  in  idiocy — a  speculation  to  which  the 
wretched  muscular  development  of  most  idiots  and 
imbeciles,  and  the  fact  that  their  mental  training  is 
most  successfully  begun  and  carried  on  through  mus- 
cular lessons,  give  some  countenance." 

Apart  from  its  effect  upon  the  mental  powers  and 
its  value  as  a  moral  gymnastic,  as  teaching  discipline, 
obedience,  and  courage,  physical  education,  according 
to  M.  Georges  Demeny,  a  noted  French  authority, 
has  three  main  objects  :  "to  confirm  health,  to  give 
a  harmonious  development  to  the  body,  and  to  teach 
how  best  to  utilize  the  muscular  force  in  the  diflferent 
applications  which  are  demanded  in  life." 

The  kind  of  exercise  which  is  most  advantage- 
ous has  not  been  definitely  settled  by  the  experts, 
and  still  less  by  the  nations.  The  Americans  and  the 
English  prefer  outdoor  games  and  athletic  sports.  The 
Germans,  and  especially  the  Swedes,  are  above  all 
patrons  of  systematic  gymnastic  exercises  directed  to 
the  development  in  due  order  and  proportion,  of  all 


332  PHYSICAL   EXERCISE. 

tlie  muscles  of  the  body.  The  truth  appears  to  lie 
between  the  two  extremes;  and  when  we  are  free  to 
choose  the  amount  and  nature  of  the  exercise,  as 
ought  to  be  the  case  with  those  who  direct  the 
physical  training  of  children  and  young  people  dur- 
ing the  period  of  growth,  both  open-air  sports  and 
regular  gymnastic  exercises  should  have  a  place  in 
our  curriculum.  For  while  outdoor  sports  and  games 
are  carried  on,  in  general,  under  far  healthier  condi- 
tions and,  as  a  rule,  afford  a  greater  amount  of  ex- 
hilaration and,  therefore,  of  recreation  than  set  exer- 
cises conducted  in  a  gymnasium  or  in  a  stuffy  bed- 
room, and  being  enthusiastically  indulged  in  are  not 
so  liable  to  be  shirked  on  slight  pretexts,  the  develop- 
ment of  muscles  and  education  of  movements  pro- 
duced by  them  is  apt  to  be  haphazard  and  lopsided. 
They  should,  therefore,  be  supplemented  by  some 
system  of  regular  gymnastics. 

During  the  period  of  development  in  childhood 
and  youth  systematic  training  of  the  body  produces 
the  greatest  results.  Dr.  Hartwell,  the  Superintend- 
ent of  Physical  Education  in  the  Boston  Public 
Schools,  who  has  had  great  experience  in  this  mat- 
ter, comes  to  the  following  conclusions : 

During  the  first  period  of  growth,  from  birth  till 
the  close  of  the  eighth  year — a  period  characterized 
especially  by  the  great  increase  in  size  and  architect- 
ural completeness  of  the  brain — both  games  and  gym- 
nastics are  valuable.  But  both  should  be  simple,  and 
should  be  directed  rather  to  the  development  of  such 
fundamental  movements  as  those  employed  in  walk- 
ing and  running,  in  bending  the  body,  and  in  main- 
taining the  erect  posture,  than  to  the  acquisition  of 


DEVELOPMENT  IN  CHILDHOOD  AND    YOUTH    333 

such  skilled  movciiieiits  as  the  movements  of  the 
hands  and  fingers  in  playing  the  piano  or  the  violin, 
or  in  handling  many  kinds  of  tools,  or  such  rapid  and 
highly  coordinated  movements  as  are  necessary  in 
many  games. 

The  second  period,  from  the  beginning  of  the 
ninth  to  the  end  of  the  sixteenth  year,  is  the  time 
of  most  rapid  growth  in  height  and  weight.  In  the 
increase  in  weight  the  muscles  take  the  chief  share, 
and  the  power  of  coordinating  movements  advances 
far  beyond  what  was  possible  in  the  first  period.  This 
is  the  most  important  period  for  physical  training, 
since  neglect  of  it  at  this  time  can  only  be  imperfectly 
.remedied  later  on.  Both  athletic  sports  and  gym- 
nastics occupy  an  important  place  as  agents  of  phys- 
ical culture  in  this  stage,  and  the  "forms  of  exercise 
should  be  more  varied,  complicated,  and  difficult  than 
in  the  previous  period." 

The  third  period  lasts  from  the  beginning  of  the 
seventeenth  to  the  close  of  the  twenty-fourth  year. 
It  is  essentially  a  period  of  mental  and  moral  devel- 
opment, and  physical  culture  should  be  directed  to 
increasing  and  perfecting  the  control  of  the  nervous 
system  over  the  muscular  movements,  and  in  partic- 
ular over  the  vastly  important  group  of  skilled  move- 
ments. During  these  years  the  handicraftsman,  as  a 
rule,  acquires  the  delicate  control  of  the  muscles  wdiich 
he  especially  uses  in  his  work,  that  manual  cunning 
through  which  he  is  to  earn  his  bread  and  which  can 
hardly  be  fully  attained  to  later  on  in  life.  To  some 
extent  the  necessary  labors  of  the  workshop  may,  if 
carried  on  under  proper  hygienic  conditions,  replace 
special  physical  culture  during  the  latter  part  of  this 


334  PHYSICAL   EXERCISE. 

period.  When  systematic  exercises  are  employed, 
those  which  educate  the  muscles,  or  rather  the  neuro- 
muscular apparatus,  should  preponderate,  while  in  the 
whole  of  the  first  period  and  first  half  of  the  second 
hygienic  forms  of  exercise  should  be  the  main  thing. 

Sports  and  Gymnastics. — Having  determined  that 
a  combination  of  athletic  sports  with  regular  gymnas- 
tics is  the  proper  method  of  physical  training,  the 
question  arises — What  are  the  best  forms  of  athletic 
sports  and  the  best  system  of  gymnastics?  No  per- 
fectly definite  answer  can  be  given.  But  if  we  keep 
in  mind  the  triple  purpose  of  ph^^sical  training,  to 
improve  and  confirm  the  health,  to  develop  the  body 
and  the  mind,  and  to  confer  upon  the  individual  the 
particular  form  of  muscular  or  manual  dexterity 
which  he  may  need  in  the  serious  business  of  his 
life,  it  is  not  difficult  to  make  combinations  of  the 
two  forms  of  exercise  which  will  approximately 
accomplish  the  end  in  view. 

Taken  by  themselves,  those  athletic  sports  which 
bring  equally  into  play  the  upper  and  lower  limbs  (as 
wrestling,  swimming,  and  rowing  with  two  sculls  or 
short  oars  and  a  sliding  seat)  are  the  best.  But  it  is 
seldom  necessary,  and  hardly  ever  desirable,  to  con- 
fine one's  self  to  a  single  sport,  and  a  game  which 
involves  chiefly  movements  of  the  legs  may  be  supple- 
mented by  a  game  or  a  gymnastic  exercise  in  which 
the  arms  are  mainly  used.  It  is  in  the  possibility  of 
graduating  and  varying  the  movements,  so  as  to  exer- 
cise every  muscle  in  its  turn,  that  scientific  gymnastics 
shows  its  superiority  over  mere  athletic  pastimes  ;  and 
of  all  the  systems  of  gymnastics  that  first  established 
by  Ling,  expanded  and  promulgated  by  Zander,  and 


THE  AMOUNT  OF  EXERCISE.  33^ 

known  now  by  the  name  of  "  Swedish  movements" 
appears  to  be  the  best  and  most  complete.  It  is  im- 
possible to  do  more  than  mention  the  subject  here, 
and  the  reader  who  desires  full  information  in  regard 
to  it  is  advised  to  consult  a  special  work  upon  the 
subject. 

The  amount  of  exercise  which  should  be  taken 
cannot  be  stated  in  definite  rules.  Many  persons,  of 
course,  remain  in  good  health  who  take  no  system- 
atic exercise  at  all.  Sometimes  the  daily  work  pro- 
vides as  much  as  is  required,  and  if  the  conditions 
under  which  manual  labor  is  carried  on  are  healthy, 
it  would  be  striving  for  an  unattainable  ideal  to 
demand,  in  addition,  a  weary  round  of  gymnastic 
exercises.  Doubtless  the  gentleman  farmer  whose 
bodily  exertion  is  confined  to  riding  about  his  fields 
or  following  the  hunt,  might  be  benefited  by  gym- 
nastic training.  But  hardly  the  greatest  enthusiast 
for  physical  education  would  expect  a  hard-working 
farmer  or  navvy  at  the  end  of  his  day's  toil  to  find 
his  chiefest  relaxation  on  the  horizontal  bar  or  even 
in  the  mildest  manipulation  of  Indian  clubs.  Ac- 
cording to  Parkes,  the  amount  of  exercise  which  an 
ordinary  man  should  take  is  equivalent  to  about  150 
foot-tons,  that  is,  the  amount  of  work  necessary  to 
raise  150  tons  to  the  height  of  one  foot.  This  is  very 
much  the  same  as  walking  about  9  miles  on  a  good, 
level  road,  or  cycling  about  18  miles  at  a  moderate 
pace,  say  9  miles  an  hour.  At  this  rate  a  cyclist  can 
cover  with  a  given  expenditure  of  energy,  measured 
by  the  amount  of  carbonic  acid  produced  and  elimi- 
nated by  the  lungs,  two  miles  to  the  foot- traveler's 
one.  But  as  the  cyclist  forces  the  pace  the  expendi- 
ture of  energy  increases  very  rapidly  owing  to  the 


336  PHYSICAL   EXERCISE. 

increase  in  the  resistance  opposed  to  his  progress  by 
the  air.  It  should  be  remembered  that  a  certain,  and 
usually  a  not  inconsiderable,  amount  of  bodily  exertion 
enters  into  the  daily  work  of  all  healthy  persons,  and 
to  this  extent  the  amount  of  systemic  exercise  may 
be  reduced. 

Excessive  Exercise. — Exercise,  as  such,  ceases  to 
be  physically  beneficial  when  pushed  to  the  point  of 
exhaustion.  The  severe  strain  of  prolonged  exertion 
may  indeed  give  rise  to  dilatation  of  the  heart,  and 
even  to  lesions  of  its  valves  and  to  aneurysm.  A 
certain  degree  of  temporary  dilatation  of  the  heart 
has  even  been  observed  in  soldiers  after  a  long  march 
in  heavy  marching  order.  A  very  rapid,  unequal, 
and  irregular  heart-beat  shows  that  the  exercise  is 
excessive  and   must  be  more  gradually  undertaken. 

Certain  diseases  of  the  respiratory  organs  may  also 
be  caused  by  excessive  exercise.  Morally,  however, 
the  severest  exercise  may  be  of  great  benefit.  For 
example,  the  grim  determination  which  keeps  the 
football-player  in  the  field  in  spite  of  bruises  and  ex- 
haustion'may  be  very  unphysiologic  and  even  injuri- 
ous as  regards  the  muscles,  but  not  necessarily  so  as 
regards  the  moral  fiber  of  the  man.  For  it  is  some- 
times well  in  more  important  moments  in  the  march 
of  life  that  when  the  weary  muscles  cry  "Halt!" 
the  steadfast  will  should  cry  "Onward!"  and  com- 
pel the  rnuscles  to  obey.  But  as  a  hygienic  train- 
ing, exercise  should  always  be  stopped  before  it 
becomes  exhausting.  This  is  especially  true  in  the 
first  and  second  periods  of  growth,  and  it  ought  to  be 
carefully  remembered  that  muscular  relaxation  is  the 
natural  complement  of  muscular  contraction,  and  rest 
the  complement  of  exercise. 


MUSCULAR   EXERCISE   IN  DISEASE.  337 

Environment  and  Clothing. — Another  point  of 
practical  importance  is  that  when  exercise  is  taken  in  a 
gyninasinni  there  shonld  be  most  thorough  ventilation, 
since  the  elimination  of  carbonic  acid  by  the  lungs 
and  the  demand  for  oxygen  by  the  muscles  are  so 
much  increased.  For  the  same  reason  no  tight 
clothing  which  would  hamper  the  free  movement  of 
the  chest  should  be  worn.  For  many  kinds  of  indoor 
exercise  it  is  well  to  strip  the  upper  part  of  the  body, 
and  there  is  no  danger  of  taking  cold  so  long  as  the 
exercise  is  going  on.  Immediately  it  is  over,  or  in 
the  intervals  of  rest,  the  body  should  be  covered. 
In  winter  the  room  should  be  properly  warmed,  but 
not  too  hot. 

Muscular  Exercise  in  Disease. — It  is  impossible 
here  to  do  more  than  mention  a  few  of  the  diseases  in 
which  local  treatment  of  the  muscles,  either  by  mas- 
sage (that  is,  stroking,  striking,  rubbing,  or  kneading) 
or  by  movements  (passive,  when  carried  out  by  the 
operator,  active,  when  carried  out  by  the  patient),  or 
by  a  combination  of  movements  and  massage,  is  em- 
ployed as  a  remedial  measure.  For  further  information 
the  reader  is  referred  to  special  works  on  this  subject. 
Such  treatment  has  been  found  of  value  in  certain 
forms  of  dyspepsia,  habitual  constipation,  gout,  de- 
rangements of  the  function  of  the  liver  without  any 
organic  disease,  obesity,  neuralgia  (including  sciatica), 
nervous  prostration,  some  forms  of  paralysis,  espe- 
cially the  acute  paralysis  of  children,  locomotor  ataxia, 
St.  Vitus'  dance,  writers'  cramp,  muscular  rheumatism, 
some  forms  of  dropsy,  certain  diseases  of  the  heart  and 
blood-vessels,  lateral  curvature  of  the  spine,  and 
sprains. 
22 


33^  PHYSICAL   EXERCISE. 

HOME  GYMNASTICS. 

By  Albert  McConaghy,  M.  D.,  of  Seattle,  Wash. 

The  series  of  home  exercises  herein  set  forth  is 
intended  to  develop  agility  and  suppleness  and  to 
encourage  the  normal  activities  of  the  muscular  sys- 
tem. The  aim  is  beneficent  physiologic  effect  of 
exercise,  rather  than  abnormal  muscle-building ;  flex- 
ibility rather  than  hardness.  The  different  move- 
ments are  so  arranged  that  those  affecting  the  same 
parts  of  the  body  do  not  immediately  follow  one 
another.  The  avoidance  of  strain  has  been  kept  in 
mind  ;  and  at  first  all  the  movements  should  be  prac- 
tised lightly,  always  stopping  short  of  actual  fatigue. 
The  effect  of  properly  regulated  exercise  is  to  impart 
a  sense  of  buoyancy  and  well-being,  rather  than  one 
of  exhaustion  or  depression. 

During  the  interval  between  the  exercises  especial 
attention  should  be  paid  to  the  acquisition  of  the 
proper  carriage  of  the  head,  shoulders,  chest,  and 
abdomen.  In  this  way  all  the  ordinary  movements, 
such  as  walking,  sitting,  stooping,  reaching,  etc., 
become  developmental  exercises  of  far  more  practical 
value  than  any  daily  system  of  home  gymnastics.  It 
must  also  be  remembered  that  no  indoor  exercise  can 
ever  supplant  the  common,  healthful  outdoor  sports, 
such  as  walking,  running,  bicycling,  swimming,  golf, 
cricket,  etc. 

The  importance  of  the  abdominal  muscles  in  all 
physical  training  should  be  emphasized.  Lydston 
says:  "Given  the  firm,  well-developed  abdominal 
muscle,  it  is  hardly  necessary  to  examine  the  rest  of 
the  muscular   system.     Any  set  of  exercises  which 


HOME    GYMNASTICS.  339 

gives  good  abdoiuinal  devclopiiiciit  imparts  an  excel- 
lent general  development.  Abdominal  protuberance 
in  individuals  out  of  condition  is  more  apparent  than 
real,  and  is  due  to  flabbiness  of  the  abdominal  walls 
rather  than  to  increase  of  fat  or  girth."  By  walking 
a  stated  distance  each  day  with  the  abdominal  muscles 
in  firm  contraction,  a  rapid  and  substantial  develop- 
ment of  their  power  and  tonicity  may  be  obtained. 
In  fact,  marked  reduction  of  fat  and  diminution  of 
abdominal  girth,  and,  more  particularly,  abdominal 
protuberance,  may  be  accomplished,  simply  by  con- 
centrating the  attention  on  the  abdominal  muscles 
and  keeping  them  in  contraction  while  walking. 

When  possible,  it  is  desirable  to  have  a  trained  medi- 
cal adviser  to  select  the  kind  of  exercises  that  are  best 
adapted  to  the  individual  requirements,  and  to  warn 
against  the  dangers  that  exercise  may  bring  to  persons 
with  organic  disease.  Pregnant  women  should  always 
avoid  movements  that  cause  strain  of  the  abdomen 
and  pelvis,  and  during  menstruation  the  same  pre- 
cautions should  obtain.  The  following  general  rules 
should  be  carefully  read  before  the  individual  exercises 
are  begun  : 

1.  Before  beginning  these  exercises  it  is  well  to 
evacuate  the  bladder,  clear  the  nose  of  all  mucus,  and 
drink  a  glass  of  water,  not  too  cold. 

2.  Except  when  stated  otherwise,  the  fundamental 
position  in  all  these  exercises  is  :  heels  together;  toes 
turned  out ;  chest  upward  and  forward  ;  arms  hang- 
ing loosely ;  abdomen  drawn  in ;  and  chin  down 
and  in. 

3.  The  time  best  adapted  for  exercising  is  in  the 
moruino;  before  breakfast.     It  is  at  this  time  that  the 


340  PHYSICAL   EXERCISE. 

vitality  is  at  its  highest,  and  the  movements  can  be 
done  with  greater  regularity. 

4.  The  room  should  be  well  ventilated  but  free 
from  drafts,  having  the  windows  down  from  the 
top  and  up  from  the  bottom.  It  is  best  to  exercise  in 
a  room  other  than  the  sleeping  apartment. 

5.  The  clothing  of  the  body  should  be  loose-fitting, 
so  as  to  leave  the  movements  of  the  body  unimpeded. 
The  night-dress  answers  this  purpose  very  well.  The 
feet  should  be  bare  or  stockinged,  as  this  allows  the 
ligaments  and  the  muscles  supporting  the  ankle-joints 
to  be  brought  into  play,  and  thus  strengthened. 

6.  The  exercises  should  be  performed  before  a 
mirror.  This  lends  interest  to  the  work  and  the 
faults  can  be  corrected  better. 

7.  The  mind  should  be  concentrated  on  the  work, 
and  each  exercise  should  be  performed  with  precision. 
If  home  gymnastics  are  practised  with  absolute  regu- 
larity, they  soon  grow  into  the  daily  habits  of  life, 
and  the  disinclination  to  exercise  which  follows  erratic 
performance  soon  disappears. 

8.  In  all  exercises  where  the  arms  are  in  extension 
they  should  always  be  stretched  out  as  far  as  possible. 

9.  As  all  these  exercises  will  have  a  tendency  to 
accelerate  the  breathing  and  the  heart's  action,  it  is 
better  to  rest  a  half  minute  after  each  movement. 

10.  The  weight  of  dumb-bells  for  male  adults 
should  be  from  one  to  three  pounds  each  ;  those  for 
ladies  and  children,  not  more  than  one-half  pound 
each. 

11.  All  the  exercises  in  this  series,  with  the  excep- 
tion of  Nos.  2,  3,  and  4,  should  be  practised  without 
dumb-bells. 


HOME    GYMNASTICS. 


341 


Fig.  70. 


1.  Stretching  Exercise (Imsj^.  70). — Lock  llie  haiuls; 
stretch  the  arms  out  in  front  on  a  level  with  the 
shoulders.  Without  bending  the  knees,  touch  the 
floor,  or  as  near  it  as  possible.  Straighten 
up  the  body,  carrying  the  arms  upward  and 
backward  above  the  head  ;  then  bring  the 
arms  down  laterally  (inclining  them  back- 
ward) to  the  level  of  the  shoulder  ;  then 
out  in  front  to  starting  position.  Through- 
out this  exercise  extend  the  arms  as  far  out 
as  they  will  go.  The  movements  should  be 
repeated  ten  times. 

2.  Dumb-bell  Exercise,  A  (Fig.  71). — 
Bells  on  the  shoulders.  As  the  right  bell  is 
carried  out  from  the  shoulder,  turn  the  head  in  the 
same  direction.  In  bringing  the  right  bell  back  to 
the  shoulder,  extend  the  left  arm  and  bell,  following 
with  the  head,  and  repeat.  Do  not  allow  the  elbows 
to  sink  below  the  level  of  the 
shoulders,  and  do  not  roll  the 
head — simply  turn  it,  keeping 
the  chin  down.  This  is  a  good 
exercise  to  develop  the  arms, 
shoulders,  and  neck,  and  to  cor- 
rect an  habitually  bad  carriage 
of  the  head.  Repeat  ten  times, 
and  gradually  increase  to  fifty 
times. 

3.  Dumb-bell  Exercise,  B 
(Fig.  72).— With  the  elbows  fixed  at  the  side,  alter- 
nately touch  the  thigh  and  chest  Avith  the  palms  up. 
This  exercise  develops  the  upper  and  lower  arms. 
Repeat  ten  times,  and  gradually  increase  to  fifty  times. 


Fig. 


342 


PHYSICAL   EXERCISE. 


4.  Dumb-bell  Exercise,  C  (Figs.  73,  74). — From  the 
position  with  the  arms  at  the  sides  carry  the  arms 
back  and  up  to  above  the  head  ;  then  down  to  the 
shoulders,  bending  the  wrists  ;  then  out  to  the  sides 
on  a  level  with  the  shoulders ;  then  back  and  down  to 
the  side  of  body.  This  exercise  is  useful  to  correct 
round-shoulders  and  contracted  chest.  Repeat  ten 
times,  and  gradually  increase  to  thirty  times.  When 
the  hands  are  elevated  above  the  head,  leg-exercise 
may  be  incorporated  in  this  movement  by  rising  on 


Fig.  72. 


Fig.  73. 


Fig.  74. 


the  toes.  As  the  arms  are  lowered  to  the  sides,  the 
body  should  be  raised  on  the  heels,  bringing  into 
action  the  extensor  muscles. 

5.  Breathing  Exercise  (Fig.  75). — With  the  hands 
on  the  posterior  aspect  of  the  thighs  slowly  exhale 
all  air  from  the  lungs.  As  the  arms  are  elevated  to  a 
position  above  the  head,  turn  the  palms  up  and  the 
arms  back  at  the  same  time,  taking  in  a  full,  slow 
breath.  As  the  arms  are  lowered,  turn  them  backward 
and  slowly  exhale.  The  inspiratory  act  should  be 
completed  just  as  the  hands  come  together  above  the 


HOME    a  YMNAS-J'ICS. 


343 


head,  and  tlie  expiratory  act  should  be  completed  as 
the  hands  reach  the  sides  of  the  body.  At  the  end  of 
the  expiratory  act,  bring  the  chest  into  a  state  of 
extreme  contraction  by  crossing  the  arms  in  front  and 
bending  forward,  at  the  same  time  making  a  forced 
expiration  to  get  rid  of  the  residual  air.  Keep  the 
mouth  closed,  and  exhale  and  inhale  through  the 
nose.  In  raising  and  lowering  the  arms  be  sure  to 
turn  them  backward,  as  this  throws  the  chest  in  a 
proper  state  of  expansion.  Quick,  jerky 
breathing  might  impair  the  elasticity  of 
the  lung-structure  in  men  past  middle  life. 
This  movement,  besides  increasing  the 
girth  and  contour  of  the  chest,  develops 
the  muscles  of  respiration  and  increases 
the  vital  capacity,  elasticity,  and  circula- 
tion of  the  lungs.  Leg-exercise  may  be 
incorporated  in  the  manner  described  in 
the  preceding  exercise.     Repeat  ten  times. 

Breathing  exercises  are  very  valuable, 
and  should  be  continually  practised.  Oc- 
casionally taking  a  deep  breath  while  walk- 
ing or  in  front  of  a  raised  window  is  a  very 
useful  practice.  Many  indoor  workers  would  be 
greatly  benefitted  if  they  would  raise  the  windows 
of  their  offices  occasionally  and  practise  deep  breath- 
ing. 

6.  Twisting  Exercise  (Fig.  76). — Rest  the  hands 
on  the  hips  with  the  thumbs  turned  back.  Fix  the 
eyes  on  a  point  on  the  walls  opposite  each  shoulder, 
so  as  to  avoid  vertigo  in  turnino-.  Then  turn  the 
body  from  side  to  side  facing  these  points,  at  the  same 
time  rubbiue  the  hands  firmlv  across  the  abdomen. 


Fig.  75. 


344 


PHYSICAL   EXERCISE. 


Fig.  76. 


In  rubbing  the  abdomen  do  not  localize  the  pressure 
to  any  one  spot,  but  cover  the  whole  abdomen.  The 
head  is  never  moved,  but  kept  firmly  in  line  with  the 
body.  This  exercise  stimulates  the  peri- 
staltic action  of  the  intestine,  and  is  useful 
in  cases  of  constipation  and  hepatic  torpor  ; 
it  is  also  indicated  when  there  is  an  excess 
of  fat  on  the  abdomen.  By  bringing  into 
play  the  rotary  muscles  and  ligaments  of 
the  spine,  this  exercise  is  an  excellent  one 
for  a  weak  back.  Repeat  ten  times,  and 
gradually  increase  to  fifty  times. 

7.  Shrug  Movement  (Fig.  ']'f). — Ele- 
vate the  shoulders  as  high  as  they  will  go 
without  drawing  in  the  head  ;  lower  the  shoulders  ; 
rotate  the  shoulders  forward  and  cross  the  arms  at  the 
wrists.  Then  throw  the  arms  up,  and  when  they 
reach  the  level  of  the  chin,  separate  them  and  carry 
them  backward,  making  a  circle  on  either 
side  of  the  body.  This  movement  is  an 
excellent  one  for  round-shoulders  and  con- 
tracted chest.     Repeat  fifteen  times. 

IvCg-exercise  may  also  be  incorporated  in 
this  exercise,  as  well  as  in  all  the  breathing 
exercises. 

8.  The  breathing  exercise  (Fig.  75) 
should  be  repeated  again  for  ten  times. 

9.  Forward  and  Backward  Bend  (Fig. 
78). — With  the  hands  on  the  hips  and  the 

thumbs  back,  bend  the  body  forward  to  a  position  at 
right  angles  with  the  legs  ;  and  as  the  muscles  of  the 
abdomen  relax,  firmly  knead  them,  going  over  the 
abdomen  from  the  lower  ribs  to  the  pubes  and  lat- 


FiG.  77. 


//().]//•:  (,- )j/a:is77cs. 


345 


erally.  As  the  body  is  bent  backward,  brace  it  by 
resting  the  hands  on  the  hips.  In  bending  backward 
allow  the  chin  to  rest  on  the  chest.  On  the  forward 
bend  tnrn  the  face  npward,  and  thns  avoid  cerebral 
congestion.  By  bringing  into  play  the  erector  spina; 
muscle,  this  movement  is  indicated  fcjr 
a  weak  back.  It  is  also  indicated  in 
constipation,  hepatic  torpor,  and  excess 
of  fat  on  the  abdominal  walls.  Repeat 
ten  times,  and  gradually  increase  to 
thirty  times. 

10.  Side  Bend  (Fig.  79). — Bend  the 
body  to  the  side  and  touch  knee,  at  the 

same  time  bringing  the  other  hand  into  the  opposite 
armpit  ;  then  reverse  and  repeat.  In  bending  to  the 
side,  keep  the  body  in  the  vertical  plane.  The  ten- 
dency to  bend  forward  or  backward  should  be  avoided. 
This  movement  strengthens  the  abdominal 
walls,  and  is,  therefore,  a  preventive  against 
hernia.  It  also  strengthens  the  back.  Re- 
peat twenty  times,  and  gradually  increase 
to  fifty. 

11.  The  breathing  exercise  (Fig.    75) 
should  be  repeated  ten  times. 

12.  Wind-mill  Movement  (Fig.  80). — 
The  body  should  be  bent  at  right  angles 
to  the  legs,  and  kept  in  this  position 
throughout  the  exercise.  Bend  the  right 
knee,  and  touch  the  floor,  or  as  near  it  as  possible, 
with  the  right  hand,  at  the  same  time  carrying  the 
left  arm  upward  and  forward  above  the  head.  Then, 
as  the  knee  is  straiQ;htened  and  the  right  hand  is 
carried  above  the  head,  the  left  knee  and  hand  assume 


Fig. 


79- 


346 


PHYSICAL   EXERCISE. 


Fig.  8o. 


the  position  that  the  right  one  previously  occupied. 
In  changing  from  one  side  to  the  other  do  not  elevate 
the  body.  This  is  a  fine  all-round  exercise,  and  is 
especially  valuable  in  cases  of  constipation,  hepatic 
torpor,  weak  back,  contracted  chest,  and 
round  or  drooping  shoulders.  Repeat  ten 
times,  and  gradually  increase  to  thirty 
times. 

13.  Floor-exercise,  A  (Fig.  81). — Lie 
at  full  length  on  the  floor  with  the  hands 
under  the  hips.  Raise  the  legs  without 
bending  the  knees  to  a  position  at  right 
angles  to  the  body,  and  return  and  repeat 
five  times,  and  gradually  increase  to  fifty. 
This  exercise  strengthens  the  abdominal 
muscles,  and  is,  therefore,  a  preventive 
against  hernia,  and  is  useful  in  cases  of  constipation 
with  fatty  abdomen. 

14.  Floor-exercise,  B  (Figs.  82,  83). — Lie  at  full 
length  on  the  floor  with  the  hands  under  the  hips. 
Bend  the  knees,  and  bring  them  up  on 
the  abdomen  and  return  to  starting 
position,  and  repeat.  Do  this  move- 
ment ten  times ;  then  bring  the  knees 
alternately  up  on  the  abdomen  fifteen 
or  twenty  times.  The  abdomen  in 
persons  unaccustomed  to  exercise  is 
ordinarily  very  weak,  and  in  such 
cases  it  is  better  to  start  with  this  exercise  until  the 
abdominal  muscles  have  been  strengthened.  Then 
the  other  floor-exercise  may  be  practised  with  greater 
ease.  This  exercise  is  useful  in  constipation  and  fat 
and  flabby  abdomen. 


Fig.  81. 


HOME    GVMNAS'J'JCS. 


347 


15.  The  breathing  exercise  (Fig.    75J  should  be 
practised  ten  times. 

16.  Relaxing  Exercise  for  the  Knee  (Fiji^.  84). — 
Steady  the  body  by  holding  on  to  a  chair.     Bring  the 


Fig.  82. 


Fig.  83. 


leg  to  the  position  illnstrated  in  Fig.  84.  Relax  the 
leg,  and  then  alternately  extend  and  flex  it  quickly. 
This  is  a  good  exercise  to  increase  the  flexibility  of 
the  knee-joint.  Repeat  ten  times,  and  gradually 
increase  to  thirty  times. 


Fig.  84. 


Fig.  85. 


Fig.  86. 


17.  Relaxing  Exercise  for  the  Hip  (Fig.  85). — 
Steady  the  body  by  holding  on  to  a  chair.  Hold  the 
leg  straight  bnt  relaxed.  Swing  it  backward  and 
forward  as  far  as  possible.  This  exercise  increases 
the  flexibility  of  the  hip-joint.  Repeat  ten  times,  and 
ofraduallv  increase  to  thirty  times. 


348  PHYSICAL    EXERCISE. 

i8.  Relaxing  Exercises  for  the  Siioulder  (Fig.  86). 
— Hold  the  arms  out  at  the  sides  on  a  level  with  the 
shoulders.  Swing  them  downward  and  cross  them 
in  front  of  the  body,  making  two  circles,  ten  times. 
Then,  from  the  starting  position,  swing  the  arms 
upward.^  and  cross  them  in  front  of  the  body,  making 
two  circles,  ten  times.  Do  both  of  these  exercises 
quickly.  This  movement  increases  the  flexibility  of 
the  shoulder. 


DOMESTIC  HYGIENE. 

By  D.  H.   BERGEY,  M.  D., 

of  philadelphia, 
Assistant  Professor  of  Bacteriology,  University  of  Pennsylvania. 


The  subject  of  domestic  hygiene  includes  all  those 
factors  in  the  home  life  of  the  individual  which  may 
be  concerned  in  affecting  his  general  health.  Many 
of  these  factors,  such  as  the  ventilation,  heating, 
water-supply,  and  sewage-disposal  of  the  house,  oper- 
ate with  equal  force  upon  all  the  occupants,  while 
other  factors,  such  as  the  nature  and  quality  of  the 
food  and  the  methods  of  preparation,  operate  more 
particularly  upon  individual  occupants.  Domestic 
hygiene,  therefore,  has  reference  to  all  those  conditions 
and  arrangements  of  the  household  which  may  exert 
a  detrimental  influence  upon  the  health  of  the  occu- 
pants. It  also  embraces  a  consideration  of  the  arrange- 
ments and  conditions  which  tend  toward  the  improve- 
ment of  the  general  health  of  the  occupants,  because 
the  general  health  may  be  conserved  not  only  by 
removing  or  avoiding  those  factors  and  conditions 
which  directly  or  indirectly  injure  health,  but  also  by 
introducing  those  factors  and  conditions  which  tend 
to  improve  the  general  health,  and  thus  fortify  the 
system  against  the  contraction  of  disease. 


349 


350  DOMESTIC  HYGIENE. 

CONSTRUCTION  AND  FURNISHING  OF  DWELLINGS. 

Location. — The  first  consideration  in  the  selection 
of  a  site  for  a  habitation  is  the  nature  of  the  soil  with 
regard  to  dampness  and  organic  impurity,  since  these 
are  the  principal  factors  in  rendering  a  soil  unhealtli- 
ful.  The  house  should  stand  upon  a  site  the  subsoil 
of  which  is  naturally  dry  or  is  properly  drained  and 
free  from  organic  impurity.  The  configuration  of  the 
surface,  the  elevation,  and  the  exposure  are  the  most 
important  factors  in  rendering  the  location  favorable 
for  a  healthy  habitation.  The  nature,  source,  and 
amount  of  the  available  water-supply  should  be  in- 
vestigated. The  possibility  for  the  economic  and  safe 
disposal  of  all  refuse  matter  must  also  be  considered. 

The  location  should  be  of  sufiicient  elevation  to 
secure  good  drainage  away  from  the  house.  A 
southern  exposure  is  preferable,  especially  in  colder 
climates.  The  proximity  of  large  bodies  of  water 
and  of  marshy  areas  also  influences  the  healthfulness 
of  the  location.  The  habitation  should  be  so  situated 
with  relation  to  others  surrounding  it  that  an  abun- 
dant supply  of  fresh  air  and  sunlight  can  be  secured. 
The  healthful  influences  of  sunlight  and  fresh  air 
cannot  be  ignored.  The  absence  of  sunlight  and  the 
deficiency  of  fresh  air  are  the  most  important  predis- 
posing factors  of  disease  iu  the  homes  of  the  poorer 
classes  in  our  large  cities.  When  the  house  is  located 
on  open  ground,  a  southern  or  a  western  exposure  is 
preferable  in  order  to  secure  the  greatest  amount  of 
sunlight  in  that  portion  of  the  house  most  constantly 
occupied.  The  windows  require  protection  with  blinds 
and   awnings  in  summer,    to  exclude  the  heat  and 


CONS TR UC TION A ND  I'UKNJSIUNG  VFlJl VK L L INGS.    3 5  I 

glaring-  effect  of  the  sun  ;  but  in  winter  the  full  and 
free  action  of  sunlight,  because  of  its  purifying  innu- 
ence  upon  the  air  of  the  house,  should  be  secured,  at 
least  during  a  part  of  each  day. 

Foundation  and  Walls. — Aside  from  the  internal 
arrangement,  the  character  of  the  walls,  the  materials 
of  which  they  are  composed,  and  the  number  of 
layers   of    these    materials    employed    are    important 


'yyy//K^/iii'f!i^ 


■'.TO.. 


-"^/'^^^^mf^^^^m^w^^^^ 


Fig.  87. — Double  foundation  walls;  h.w,  air-space  between  inner  and 
outer  walls  of  house ;  //,y,  air-space  in  foundation-walls;  a,  arched  roof  of 
basement;  r.a,  r.a,  reversed  arcli  of  basement  floor. 

factors  in  determining  the  healthfulness  of  the  house. 
So  far  as  materials  are  concerned,  there  is  no  great 
hygienic  difference  in  the  selection  of  wood,  stone, 
or  brick,  but  the  walls  and  foundation  of  the  house 
should  be  so  constructed  as,  so  far  as  possible,  to 
exclude  dampness.  This  can  be  accomplished  by 
means  of  double  walls — that  is,  by  providing  an  air- 
space between  the  inner  and  outer  surfaces  (Fig.  87). 


352  DOMESTIC  HYGIENE. 

In  this  manner  the  walls  are  rendered  damp-proof  and 
yet  are  not  made  impervions.  The  foundations  and 
walls  should  be  as  dry  as  possible,  and  in  damp  soils 
this  can  be  secured  only  by  draining  the  subsoil  below 
the  foundations,  and  by  cementing  the  foundation- 
walls  and  cellar-floor. 

The  roof  of  the  house  must  be  carefully  constructed 
and  frequently  examined  in  order  to  prevent  leaking. 
The  material  of  which  the  roof  is  constructed  is  of 
no  hygienic  significance  so  long  as  it  excludes  rain. 
The  rain-water  falling  upon  the  roof  should  be  con- 
ducted away  from  the  house  through  proper  rain- 
leaders,  so  as  to  prevent  the  soil  of  the  locality  from 
becoming  unduly  damp  from  this  cause. 

The  internal  arrangement  of  the  house  is  of  equal 
importance  with  the  site,  materials,  and  mode  of 
construction.  The  height  and  number  of  stories,  the 
size  and  arrangement  of  the  rooms,  and  the  disposi- 
tion of  doors  and  windows,  all  have  an  important 
influence  upon  the  health  of  the  occupants  of  a 
house. 

The  minimum  height  of  the  stories  may  be  stated 
as  nine  feet,  while  the  maximum  height  may  be  placed 
at  fourteen  feet.  The  amount  of  cubic  space  which 
should  be  supplied  for  each  person  is  about  looo  cubic 
feet.  A  room  9  X  12  X  9  feet  would  contain  the 
amount  of  cubic  space  required  for  an  adult.  With 
the  height  of  a  room  less  than  nine  or  more  than 
fourteen  feet,  the  problem  of  ventilation  is  rendered 
more  difficult.  In  a  room  less  than  nine  feet  in 
height  the  other  dimensions  of  space  must  be  increased 
beyond  those  just  given  in  order  readily  to  supply  the 
requisite  amount  of  fresh  air  per  individual,  and,  in 


CONS TR UCTION  AN/)  FURN/SIUNG  OF  J)  II  'AY,  /.  MV/.V.    353 

consequence,  llic  venlikition  and  healing  become  less 
efficient,  because  it  is  more  difficuU  to  secure  rej^ular 
movements  of  vohimes  of  air  on  a  horizontal  pkme 
than  in  a  perpendicular  direction.  On  the  other  hand, 
in  rooms  over  fourteen  feet  in  height,  there  is  a  ten- 
dency for  the  air  to  stagnate  in  the  upper  portion  of 
the  room  and  thus  hinder  the  regular  and  complete 
displacement  of  the  contained  air  by  fresh  air. 

So  far  as  possible,  the  rooms  should  be  so  arranged 
as  to  minimize  the' energy  expended  in  going  from 
one  part  of  the  house  to  another  ;  consequently  stair- 
ways should  be  avoided  as  much  as  possible.  Unless 
the  price  of  land  demands  it,  the  house  should  not  be 
more  than  t"wo  stories  in  height.  This  will  necessi- 
tate the  extension  of  the  building  on  a  larger  area  of 
ground  than  is  otherwise  the  case.  So  far  as  the 
architectural  conditions  are  concerned,  the  effect  can 
usually  be  made  as  pleasing,  if  not  more  so,  in  a  two- 
story  house  as  in  one  that  is  three  or  four  stories  in 
height.  There  is  no  doubt  that  the  ventilation  and 
heating  of  a  house  two  stories  in  height  are  somewhat 
more  difficult  than  in  one  having  the  same  number 
of  rooms,  but  which  is  three  or  four  stories  in  height, 
owing  to  the  difficulty  of  distributing  currents  of  air 
in  a  horizontal  direction.  This  difficulty  does  not, 
however,  outweigh  the  evident  advantages  affi^rded  in 
other  directions. 

The  cellar  should  be  well  lighted  and  properly 
ventilated,  and  no  refuse  matter  should  be  allowed  to 
accumulate  in  it.  If  the  cellar  is  allowed  to  become 
the  dumping-place  for  refuse  materials,  the  contained 
air  will  become  tainted  and  find  its  way  into  the  living 
rooms  and  vitiate  the  air  of  the  entire  house. 
23 


354  DOMESTIC  HYGIENE. 

The  kitchen  should  also  be  well  lighted  and  venti- 
lated, because  the  most  important  work  of  the  house- 
hold must  be  performed  in  this  room.  Scrupulous 
cleanliness  should  be  exacted  in  the  kitchen.  The 
sinks  should  be  carefully  cleaned  each  day,  so  as  to 
avoid  the  accumulation  in  them  of  grease  and  refuse 
matter,  from  which  foul  odors  may  be  generated. 
The  refrigerator  should  receive  especial  attention 
with  regard  to  cleanliness.  Unless  the  refrigerator  is 
kept  scrupulously  clean,  odors  will  develop  that  will 
taint  the  food  contained  in  it  and  perhaps  prove  a 
cause  of  ill-health  in  the  household. 

All  the  stairways  should  have  an  easy  slope.  The 
steps  should  be  broad  and  low,  so  as  to  minimize  the 
energy  expended  in  going  from  one  story  to  another. 
The  hallways  should  be  well  lighted,  so  as  to  avoid 
dark  corners  in  which  dust  may  be  allowed  to  remain 
unnoticed  and  undisturbed.  All  unnecessary  draperies 
and  curtains  should  be  avoided,  because  they  permit 
dust  to  settle  in  them.  The  curtains  should  be  com- 
posed only  of  such  materials  as  permit  of  frequent 
laundering.  Plush  or  velvet-covered  furniture  is  also 
objectionable,  because  it  does  not  admit  of  satisfactory 
cleaning.  Where  such  furniture  is  in  use,  it  would 
be  preferable  to  provide  linen  covers  which  could  be 
frequently  removed  and  laundered. 

The  disposition  of  doors  and  windows  should 
be  such  as  to  facilitate,  so  far  as  possible,  the  admis- 
sion of  fresh  air  and  sunlight,  the  two  principal 
health-giving  agencies  in  nature.  An  effort  should 
be  made  to  have  doors  and  windows  on  opposite 
sides  of  rooms,  in  order  to  facilitate  cross-ventila- 
tion. 


CONSTRUCTION  AND  FURNISinNG  OF  DIVKI. TINGS.    355 

Walls  and  Wall-coverings. — The  hy<;iciiic  in- 
fluence of  wall-coverings  is  frequently  neglected.  It 
is  usually  the  custom  to  cover  the  vi'alls  with  wall- 
paper, and  when  this  becomes  soiled,  another  layer  is 
placed  over  it.  This  process  is  often  continued  until 
the  weight  of  the  paper  on  the  wall  is  so  great  as  to 
become  detached  en  masse.  The  practice  of  repaper- 
ing  without  previous  removal  of  the  old,  soiled  paper 
cannot  be  condemned  too  strenuously.  In  this  manner 
the  filth  accumulated  through  months  and  years  of 
constant  occupation  is  merely  covered  over,  and  may 
give  rise  to  serious  illness  in  the  occupants,  and  is 
especially  likely  to  retain  the  germs  of  disease  in  the 
house  if  efficient  disinfection  is  not  practised. 

When  repapering  is  necessary,  the  soiled  paper 
should  always  be  removed  and  the  walls  scrubbed 
with  some  efficient  antiseptic  solution,  such  as  chlorid 
of  lime,  before  a  new  coat  of  paper  is  applied.  The  use 
of  wall-papers  cannot  be  recommended  from  a  hygienic 
standpoint.  It  would  be  far  preferable  to  have  the 
walls  painted  or  kalsomined.  Painted  walls  may  be 
scrubbed  and  cleaned  without  suffering  any  detriment. 
Kalsomined  walls  can,  when  soiled,  receive  a  fresh 
coating  of  kalsomine.  The  use  of  enameled  brick 
for  interior  walls,  with  metal  ceilings,  gives  a  most 
pleasing  effect  and  meets  all  hygienic  requirements. 

There  is  no  doubt  that,  at  least  in  part,  the  robust 
health  of  our  ancestors  is  to  be  attributed  to  the  fact 
that  wall-papers  were  not  then  in  general  use.  Usually 
the  interior  walls  received  frequent  and  liberal  coatings 
of  whitewash,  and  in  this  way  were  rendered  aseptic  at 
quite  frequent  intervals.  It  is  well  known  that  freshly 
slaked  lime  is  one  of  the  most  efficient  disinfectants. 


356  DOMESTIC  HYGIENE. 

Floors  and  Floor-coverings. — It  is  not  generally 
recognized  that  the  floors  and  floor-coverings  in  most 
houses  are  mere  receptacles  for  filth  carried  on  our 
shoes  from  the  streets.  The  dirt  is  rubbed  off  on 
carpets  and  other  floor-coverings,  and  settles  there,  to 
be  distributed  into  the  air  of  rooms  through  dusting 
and  sweeping,  thus  becoming  a  direct  menace  to  the 
health  of  the  occupants.  The  floors  beneath  the 
carpets  are  often  so  constructed  as  to  afford  additional 
receptacles  for  the  surplus  dust  which  penetrates  the 
floor-coverings.  Under  these  conditions  the  slightest 
agitation  of  the  floor-coverings  by  sweeping  will  serve 
to  raise  clouds  of  dust  laden  with  the  germs  of  dis- 
ease, and  there  is  no  doubt  that  this  is  a  fruitful  mode 
of  disseminating  disease. 

The  floors  should  be  impervious  and  free  from 
cracks  and  crevices.  Wooden  floors  can  be  placed 
in  such  a  condition  only  by  means  of  oil  and  paint. 
Here  again  the  economy  practised  in  the  rural  dis- 
tricts— that  o{  paintmg  the  floors  instead  of  covering 
them  with  carpets — tends  to  lessen  the  danger  of  dis- 
seminating disease.  It  is  true  that,  to  some  extent, 
the  same  conditions  are  found  in  some  of  the  better 
class  of  modern  dwellings.  Very  pleasing  effects  can 
be  obtained  by  means  of  inlaid  floors  of  different 
colored  woods. 

With  painted  floors,  the  use  of  carpets  and  Japanese 
matting  as  a  floor-covering  is  not  required.  Instead 
of  carpets  and  matting,  a  few  rugs  may  be  used,  and 
these  meet  all  the  hygienic  requirements.  They  are 
not  permanently  fastened  to  the  floors,  as  is  the  case 
with  carpets,  consequently  they  can  be  removed 
bodily  at  frequent  intervals  and  the  floor  thoroughly 


VENTILATION.  357 

cleaned.  Carpets,  on  tlic  oilier  hand,  arc  nsnally 
allowed  to  remain  in  ])lace  for  inonLlis  and  even  years, 
resnlting  in  an  astonishing  accnmnlation  of  dnst 
nnderneath,  even  with  the  greatest  degree  of  cleanli- 
ness permissible  under  such  conditions. 

VENTILATION. 

The  necessity  for  maintaining  the  purity  of  the  air 
of  our  homes  is  generally  recognized.  During  the 
winter  months  it  is  impossible  to  keep  the  contained 
air  of  the  same  degree  of  purity  as  the  outside  air, 
since  there  is  a  certain  amount  of  accumulation  of 
the  impurities  arising  from  respiration,  perspiration, 
and  combustion.  It  should  be  our  endeavor,  how- 
ever, to  keep  this  accumulation  as  low  as  possible. 
This  is  accomplished  by  dilution — that  is,  by  bring- 
ing in  a  constant  supply  of  fresh  outside  air  to  displace 
an  equal  portion  of  the  contained  air.  This  is  known 
as  ventilation.  The  impurities  arising  from  respira- 
tion, perspiration,  and  combustion  which  make  it 
necessary  to  institute  measures  to  bring  about  venti- 
lation are,  principally,  carbon  dioxid,  water-vapor, 
and  various  forms  of  dust.  While  these  substances 
are  not  in  themselves  directly  poisonous  in  the 
amounts  usually  present  in  the  air  of  ordinary  dwell- 
ings, they  are,  nevertheless,  injurious  wdien  con- 
stantly present  in  relatively  large  amounts  for  long 
periods  of  time,  because  of  their  depressing  or  irrita- 
ting influence,  and  on  account  of  the  corresponding 
diminution  in  oxygen,  the  life-giving  agent  of  the 
air. 

The  relative  proportion  of  carbon  dioxid  in  the  air 
is  taken  as  an  indication  of  its  purity.     This  is  done. 


358 


DOMESTIC  HYGIENE. 


not  because  the  carbon  dioxid  is  in  itself  injurious  in 
the  amounts  usually  encountered,  but  because  it  is 
readily  estimated  and  has  been  found  by  de  Chaumont 
to  be  a  fair  indicator  of  the  relative  purity  of  the  air. 
The  estimation  of  the  amount  of  carbon  dioxid  in 
air  may  be  made  in  a  variety  of  ways,  but  all  the 
methods  are  dependent  upon  the  same  principle — the 
amount  of  precipitation  produced  in  a  definite  quan- 
tity of  lime-water  (or  similar  solution)  by  a  known 


□ 


/ 

^  s 

LIMEWATER 

6tOZ, 
NOrfT.    10 

I    J, 

UMEWSID 

1 

Fig. 


-Household  method  of  estimating  carbon  dioxid  (Fox). 


volume  of  air.  A  simple  household  method  for 
roughly  estimating  the  proportion  of  carbon  dioxid 
in  air  consists  in  washing  measured  quantities  of  the 
air  with  \  ounce  of  lime-water  in  glass-stoppered 
bottles  of  different  sizes  (Fig.  88). 

It  must  be  remembered  that  outside  air  constantly 
contains  carbon  dioxid  in  amounts  ranging  from  0.03 
to  0.05  per  cent.  So  long  as  the  contained  air  of  our 
houses  contains  carbon  dioxid  as  the  result  of  respira- 


VEN77/.A77()N.  359 

tory  impurity,  not  exceeding  0.05  to  0.07  per  cent., — 
that  is,  0.02  per  cent,  in  excess  of  the  outside  air, — 
we  may  re^^ard  the  ventilation  as  satisfactory. 

DeChaumont  found  that  the  relative  purity  of  the 
air  of  a  room  can  be  determined  in  an  api)roximate 
manner  by  the  olfactory  sense.  The  first  impression 
obtained  on  entering  such  a  room  from  the  outside 
air  is  the  best  criterion  of  its  purity.  The  odor  of 
organic  matter  given  off  from  the  bodies  of  the  occu- 
pants in  a  crowded  room  is  very  offensive,  and  the 
relative  amount  present  is  readily  detected.  Pure  air 
will  appear  fresh  and  sweet,  while  organic  impurities 
will  render  the  air  close,  very  close,  or  fetid,  accord- 
ing to  the  amount  present. 

In  overcrowded  rooms  there  is  always  an  excess  of 
humidity  in  the  air.  The  moisture  in  the  air,  when 
excessive,  becomes  a  source  of  discomfort,  because  it 
diminishes  the  normal  evaporation  of  moisture  from 
the  surface  of  the  body,  and  consequently  favors  the 
retention  of  impurities  in  the  body  that  should  be 
regularly  eliminated.  In  this  manner  excessive 
humidity  of  the  air  may  also  prove  injurious  to 
health.  The  amount  of  moisture  in  the  air  that  is 
most  healthful  is  about  75  per  cent,  of  saturation. 

The  problem  of  ventilation  is  not  an  easy  one  to 
solve.  It  is  a  simple  matter  to  bring  in  fresh  air,  but 
when  the  outside  temperature  is  near  the  freezing- 
point,  it  is  impossible  to  ventilate  by  merely  opening 
the  doors  and  windows.  On  this  account  ventilation 
is  intimately  connected  with  the  problem  of  heating, 
since  the  cold  outside  air  admitted  displaces  a  corre- 
sponding amount  of  warm  air.  In  the  ventilation  of 
buildings  we  aim  to  brine  in  fresh  outside  air  in  such 


36o 


DOMESTIC  HYGIENE. 


a  manner  as  to  avoid  drafts,  since  there  is  probably 
nothing  more  detrimental  to  health  than  a  draft  of 
cold  air  striking  any  portion  of  the  body.  We  seek, 
therefore,  to  bring  in  the  fresh  air  in  a  number  of 
small  continuous  streams  so  as  to  prevent  the  sudden 
cooling  of  the  contained  air,  as  well  as  to  avoid  the 
production  of  drafts.      The  sensation  of  draft  may 

also  be  overcome  by 
bringino-  in  the  fresh  air 
at  such  a  height  that  it 
cannot  impinge  directly 
on  the  bodies  of  the  oc- 
cupants and  at  a  temper- 
ature approximating  that 
of  the  air  of  the  room 
itself. 

Ventilation  may  be 
brought  about  either  by 
natural  means,  as  the  re- 
sult of  movements  in- 
duced by  heated  columns 
of  air  in  ventilating  flues, 
or  by  artificial  means,  as 
with  fans  or  blowers. 
The  former  is  known  as 
natural  ventilation,  and  the  latter,  as  artificial  venti- 
lation. The  frequency  with  which  the  air  of  a  room 
is  changed  will  depend  upon  its  size  and  the  number 
of  the  occupants.  A  space  of  looo  cubic  feet  occu- 
pied by  one  individual  will  require  a  complete  change 
of  the  air  three  times  in  each  hour,  in  order  to  main- 
tain its  purity  at  the  required  standard. 

Many  devices  have  been  suggested  for  bringing  in 


Fig.  89. — Window-ventilation. 


HE  A  TING.  3O I 

fresh  outside  air  in  natural  ventilation.  'J'lic-  ,siiii])kst 
of  these  is  the  insertion  of  a  board  under  the  lower 
sash  of  a  window  (I'ig'.  89).  This  sinijjle  arranj^c- 
ment  allows  the  entrance  of  fresh  air  at  the  junction 
of  the  lower  and  the  upper  sash,  and  gives  the  incoming 
air  an  upward  tendency.  The  cold  air  rises  toward 
the  ceiling  and  is  distributed  in  all  directions  and 
then  gradually  sinks  to  the  floor. 

In  artificial  respiration  the  fresh  air  is  either  pro- 
pelled through  the  house  by  means  of  a  blower,  or 
the  contained  air  is  abstracted  by  the  same  means, 
the  fresh  air  in  this  instance  gaining  entrance 
through  cracks  in  doors  and  windows  and  through 
porous  walls  and  floors,  or  by  means  of  special  inlets. 
The  results  obtained  by  these  methods — propulsion 
or  abstraction — are  equally  satisfactory,  although  the 
propulsion  method  is  preferable,  because  the  incom- 
ing air  may  be  warmed  by  passing  it  through  or  over 
steam  coils,  and  the  point  of  intake  may  also  be 
selected  with  reference  to  the  greatest  purity  of  the 

air. 

HEATING. 

The  object  in  heating  our  dwellings  is  to  maintain 
the  temperature  at  or  near  such  a  point  as  has  been 
found  most  agreeable  and  most  efficient  in  conserving 
the  heat  of  the  body.  A  temperature  of  70°  F.  is 
agreeable  to  most  persons.  In  the  absence  of  arti- 
ficial heat,  in  winter,  our  bodies  lose  their  own  heat 
quite  rapidly  and  suflTer  in  consequence. 

Heat  may  be  supplied  in  several  different  ways,  as 
by  means  of  stoves,  open  fire-places,  hot-air  furnaces, 
petroleum  heaters,  gas-radiators,  and  steam  or  hot- 
water  radiators.     When  the  heated  object  is  placed  in 


362  DOMESTIC  HYGIENE. 

the  room  to  be  heated,  we  have  heating  by  direct 
radiation,  and  when  it  is  placed  in  some  other  part 
of  the  house,  the  heating  is  by  indirect  radiation. 
Stoves  give  rise  to  a  great  deal  of  annoyance,  be- 
cause of  the  dust  produced  and  because  of  the  un- 
equal distribution  of  the  heat.  The  same  objections 
apply  to  open  fire-places,  and  these  also  give  rise  to 
unpleasant  drafts.  Similar  objections  may  be  raised 
with  regard  to  heating  with  petroleum  and  gas.  In 
addition  these  fuels  utilize  large  quantities  of  oxygen 
and  thus  rapidly  impoverish  the  air  of  the  rooms 
heated  in  this  manner. 

As  has  already  been  stated,  ventilation  is  intimately 
connected  with  heating,  since  it  is  impossible  to  bring 
in  fresh  outside  air  without  displacing  a  correspond- 
ing amount  of  the  warm  contained  air.  For  this 
reason  it  is  more  economical  and  satisfactory  to  ven- 
tilate by  means  of  previously  warmed  air,  thus  com- 
bining ventilation  and  heating.  This  combined  sys- 
tem of  ventilation  and  heating  is  exemplified  in 
ordinary  furnace-heatings  in  which  the  only  source 
of  heat  is  that  supplied  by  the  air  which  has  passed 
through  the  furnace  and  become  heated.  There  are 
several  other  systems  of  combined  ventilation  and 
heating  in  use,  the  most  satisfactory  of  which  is  by 
steam  radiators  placed  in  stacks ^  through  and  over 
which  the  fresh  outside  air  passes  on  its  way  to  the 
different  parts  of  the  house.  This  combined  system 
of  ventilation  and  heating  is  now  in  very  general 
use,  not  only  for  private  dwellings,  but  also  for  office- 
buildings,  hospitals,  hotels,  and  schools.  By  regu- 
lating the  size  of  the  flues  and  the  speed  of  the 
blower,  a  fairly  definite  amount  of  warm  air  may  be 


JIEA'riNG.  363 

supplied  to  each  room  according  to  its  relative  si/.c 
and  location.  In  ordinary  dwellings  it  is  usually  un- 
necessary to  employ  a  blower  to  propel  the  heated 
air,  as  the  increased  temperature  imparted  to  it  while 
passing  over  the  steam-coils  causes  it  to  expand  and 
thus  gives  it  an  upward  tendency.  The  expansion 
of  the  air  brought  about  in  this  manner  is  usually 
sufficient  to  produce  the  movement  necessary  for  con- 
ducting it  to  all  parts  of  the  house. 

In  such  a  combined  system  of  ventilation  and  heat- 
ing it  is  necessary  to  remember  that  exits  of  corre- 
sponding size  must  be  provided  in  each  room  for  the 
escape  of  an  equal  volume  of  the  contained  air, 
since  no  more  fresh  heated  air  can  be  brought  into  a 
room  than  the  amount  of  contained  air  that  is  leav- 
ing it  at  the  same  time.  Oversight  of  this  necessary 
provision  is  frequently  the  cause  for  dissatisfaction 
with  this  method  of  ventilation  and  heating. 

In  the  heating  of  dwellings  two  things  are  to  be 
guarded  against  ;  these  are  excessive  temperature 
and  undue  dryness  of  the  air.  Aside  from  these  two 
factors,  the  heating  of  dwellings  has  no  particular 
hygienic  significance,  except  in  the  production  and 
distribution  of  dust  and  the  gases  resulting  from 
combustion.  Excessive  temperature,  undue  dryness, 
as  well  as  undue  amounts  of  dust,  are  most  fre- 
quently encountered  in  furnace-heated  houses. 

Excessive  temperature  may  be  avoided  by  proper 
control  and  regulation  of  the  fire.  Undue  dryness 
of  the  air  is  less  readily  controlled.  During  the 
winter  months  the  relative  humidity  of  the  outside 
air  is  generally  not  very  low,  but  by  the  time  it  has 
passed  through  the  furnace  and   become  heated,   its 


364  DOMESTIC  HYGIENE. 

relative  humidity  is  excessively  low,  simply  on  ac- 
count of  the  increase  in  temperature. 

The  dryness  of  the  air  may  be  overcome,  at  least 
in  part,  by  keeping  the  water-reservoirs  of  the  fur- 
nace filled  with  water.  This  will  give  opportunity 
for  the  air  to  take  up  moisture  on  its  way  to  the 
rooms  to  be  heated.  Besides  this,  several  other 
measures  have  been  introduced  for  increasing  the 
humidity,  such  as  placing  a  moistened  sponge  or  a 
small  jug  filled  with  water  before  each  inlet-opening. 

The  production  and  distribution  of  dust  are 
readily  controlled  by  the  person  attending  to  the 
furnace-fire.  By  opening  the  dust-flues  before  shak- 
ing or  dumping  the  fire,  most  of  the  dust  passes  up 
the  chimney  instead  of  finding  its  way  into  the  upper 
portion  of  the  house  through  the  hot-air  shafts.  The 
hot-air  shafts  should  be  taken  apart  and  cleaned  each 
fall  before  the  furnace-fire  is  started,  in  order  to 
remove  the  dust  accumulated  during  the  summer, 
otherwise  this  dust  will  find  its  way  into  the  living- 
rooms  in  the  first  weeks  during  which  the  furnace  is 
in  use,  and  hence  may  prove  of  decided  detriment 
to  the  health  of  the  occupants.  It  is  probable  that 
this  dust  is,  at  least  in  part,  answerable  for  the  colds 
contracted  at  this  season  of  the  year,  because  of  its 
irritating  effect  upon  the  mucous  membrane  of  the 
respiratory  tract. 

Devices  for  Cooling  the  Air. — During  the  summer 
months  it  is  desirable  to  cool  the  air.  The  method 
in  common  use  is  by  means  of  small  electric  fans. 
These  serve  to  propel  the  air  through  a  room  at  a 
high  rate  of  speed,  and  thus  bring  about  a  cooling 
effect  by  the  greater  evaporation  from  the  surface  of 


///■;,/  'j'iNG. 


3^^5 


the  body  because  of  the  rapid  renewal  of  the  sur- 
rounding air.  This  method  of  cooling  the  air  is  ap- 
plicable on  the  small  scale,  as  each  fan  acts  only  in 
the  room  in  which  it  is  placed. 

The  air  of  an  entire  house  may  be  cooled  by  pass- 
ing it  through  a  chamber  filled  with  ice.  This, 
however,   is  a  very  expensive  method.     Passing  the 


Fig.  90. — The  "  Nevo,"  an  apparatus  for  cooling  the  air. 

incoming  air  through  a  screen  over  which  a  sprav  of 
ice-water  is  falling  will  also  serve  to  cool  the  air. 
Liquid  air  has  been  introduced  recently  as  a  means 
of  cooling  the  air  in  summer,  and  has  proved  satis- 
factory in  the  ventilation  of  theaters.  Within  recent 
years  Professor  Gates,  of  Washington,  devised  an 
apparatus  for  cooling  the  air,  which,   it  is  claimed. 


366  DOMESTIC  HYGIENE. 

can  be  operated  more  cheaply  than  a  stove.  Pro- 
fessor Willis  Moore,  of  the  United  States  Weather 
Bureau,  has  also  devised  an  apparatus — the  "  Nevo  " 
(Fig.  90) — for  this  purpose.  Neither  of  these  appli- 
ances has  as  yet  been  so  perfected  as  to  pass  beyond 
the  experimental  stage.  Some  apparatus  of  this  kind 
is  greatly  needed. 

LIGHTING. 

The  subject  of  lighting  has  already  been  discussed 
in  detail  in  the  chapter  on  the  Eye  (pp.  234  and  244), 
and  requires  no  additional  consideration  here. 

WATER=SUPPLY. 

Consideration  of  the  purity  of  tine  water-supply 

is  of  equal  importance  with  that  of  the  purity  of  the 
air-supply.  According  to  the  teaching  of  sanitarians 
of  the  present  day,  the  principal  water-borne  diseases 
are  typhoid  fever,  cholera,  diarrhea,  and  dysentery. 
The  specific  causes  of  typhoid  fever,  cholera,  and 
dysentery  are  now  generally  accepted  to  be  well- 
known  species  of  bacteria.  The  mode  of  entrance 
of  these  bacteria  into  the  system  is  by  way  of  the 
mouth,  and  takes  place  usually  through  the  ingestion 
of  infected  water  or  infected  food.  The  bacteria 
causing  these  diseases  are  thrown  off  from  the  body 
of  the  patient  by  way -of  the  intestinal  or  urinary 
tract — that  is,  with  the  feces  or  urine.  From  these 
facts  it  will  be  seen  that  we  usually  contract  typhoid 
fever,  cholera,  or  dysentery  by  taking  into  our 
stomachs  something  which  had  previously  passed 
through  the  intestinal  tract  of  some  other  person. 
Hence  it  will  be  evident  how  important  it  is  to  have 


WATKR-SUPJ'LY.  367 

a  water-supply  that  is  free  from  these  infective 
materials. 

Municipal  Water-supplies. — In  thickly  populated 
districts  where  the  citizens  have  joined  together  to 
form  municipal  governments,  the  individual  has  the 
right  to  expect,  and  even  demand,  of  the  municipal 
authorities  certain  safeguards  against  agencies  likely 
to  jeopardize  his  health.  In  such  communities  the 
regulation  of  the  purity  of  the  water-supply  is  trans- 
ferred from  the  individual  to  the  municipal  authori- 
ties. The  individual  has  a  right,  therefore,  to  de- 
mand of  the  municipality  a  water-supply  that  is 
ample  in  quantity  for  all  ordinary  domestic  uses  and 
reasonably  free  from  materials  detrimental  to  health. 

In  localities  where  natural  water,  ample  in  quantity 
and  of  reasonable  purity,  cannot  be  obtained,  it  is  in- 
cumbent upon  the  municipal  authorities  to  purify  the 
water  that  is  least  polluted  and  most  readily  obtained. 
The  question  of  municipal  water-supply  has  received 
a  great  deal  of  attention  from  sanitarians  in  recent 
years.  Purification  plants  have  been,  or  are  now 
being,  installed  in  a  number  of  municipalities.  The 
method  of  purification  employed  in  any  city  varies 
with  the  inherent  character  of  the  water  of  the 
locality  ;  for  instance,  the  water  of  the  Ohio  and 
Potomac  Rivers  has  been  found  to  be  of  such  a  char- 
acter as  to  be  more  satisfactorily  purified  by  the 
method  of  rapid  filtration  through  sand,  with  the 
addition  of  alum  as  a  coagulant  to  restrain  the  fine 
particles  of  clay  found  in  these  waters.  The  water 
of  most  rivers  of  the  Southern  States  is  of  a  similar 
nature.  The  water  of  the  rivers  of  the  Middle 
and  New  England  States  generally  contains  smaller 


3^8  DOMESTIC  HYGIENE. 

amounts  of  clay,  and  for  the  purification  of  these 
waters  the  slow  sand-filters,  without  the  use  of  alum, 
have  been  found  most  satisfactory. 

Domestic  Filtration. — In  those  municipalities  in 
which  the  water-supply  is  not  free  from  danger  to 
health,  and  where  the  local  finances  have  thus  far 
prevented  the  installation  of  satisfactory  purification 
plants,  the  individual  householder  is  obliged  to  apply 
such  measures  for  rendering  the  water-supply  safe  as 
may  be  required  by  the  local  conditions.  In  many  cities 
and  towns  where  the  water-supply  has  been  notoriously 
bad  for  a  number  of  years,  individual  householders 
have  resorted  to  a  variety  of  means  for  remedying 
the  evil.  Many  of  the  hospitals,  hotels,  apartment- 
houses,  schools,  and  private  dwellings  are  equipped 
with  individual  filters  which  operate  on  the  principle 
of  the  rapid  sand-filters,  using  alum  as  a  coagulant. 
These  filters  purify  all  the  water  entering  the  build- 
ing, and  if  properly  constructed  and  intelligently 
managed,  prove  quite  efficient.  Many  householders 
purify  the  water  used  for  cooking  and  drinking  by 
means  of  filters  composed  of  cylinders  of  unglazed 
porcelain,  baked  infusorial  earth,  or  of  sandstone 
(Fig.  91). 

These  filters  act  merely  as  strainers,  since  their  fine 
pores  prevent  the  passage  of  any  bacteria.  The  ser- 
viceability of  these  filters  is,  however,  of  short  dura- 
tion. Usually  in  a  few  days  the  bacteria  in  the  water 
grow  through  the  pores  of  the  filter  and  appear  in 
the  filtered  water.  Unless  the  filters  are  boiled  or 
baked  at  frequent  intervals,  the  filtered  water  will  in 
time  contain  more  bacteria  than  the  applied  water. 
It  is  necessary,  therefore,  to  scrub  and  boil  filters  of 


J'LUA//U\(J  AN  J)   J)  R.UNA  CI'..  369 

this  class  once  or  twice  a  week  in  order  to  maintain 
their  efficiency. 

Other  measnres  adopted  for  t]ie  ])nrification  of 
drinking-water  in  the  honsehold  whicli  are  of  vahie 
are  distillation  and  boiling.     Special  forms  of  appa- 


FlG.    91.— Household    filter— Berkefeld  :        FlG.  92. — Domestic  water-still. 
a,  outlet  for  unfiltered  water;  b,  outlet 
for  filtered  water. 

ratus  for  distillinof  drinkinsf-water  have  been  devised 
(Fig.  92).     These  yield  a  pure  and  satisfactory  water. 

PLUMBING   AND   DRAINAGE. 

Sewers  and  Drains.  —  Where  a  general  water- 
supply  has  been  introduced,  it  is  necessary  to  provide 
means  for  the  removal  of  the  waste-water.  In  most 
modern  towns  a  system  of  underground  drains  or 
sewers  has  been  installed  in  order  to  carry  the  house- 
hold wastes  away  from  the  town  limits.  Where  such 
a  system  of  sewers  has  been  provided,  the  household 
24 


370 


DOMESTIC  HYGIENE. 


waste  of  each  house  is  discharged  through  a  four-  to 
six-inch  iron  pipe  into  the  sewer  under  an  adjoining 
street.  The  large  iron  pipe  which  carries  the  sewage 
away  from  the  house  is  known  as  the  house-drain  or 
soil-pipe,  and  into  this  drain  is  discharged  all  the 
waste  from  kitchen-sinks,  laundry,  bath-tubs,  water- 
closets,  and  wash-basins. 

All  the  connections  with  the  house-drain,  such  as 
bath-tubs,  sinks,  water-closets,  etc.,  are  constructed 
in  such  a  manner  as  to  retain  a  small  amount  of 


Fig.  93. — Anti-D  trap; 

water  in  a  bend  of  the  pipe  so  as  to  seal  the  connection 
and  thus  prevent  the  escape  of  gases  from  the  house- 
drain  into  the  rooms.  Such  a  water-seal  in  the  pipes 
is  called  a  "  trap  "  (Fig.  93). 

In  the  plumbing  of  modern  houses  the  house-drain 
is  constructed  of  heavy  wrought  or  cast-iron  pipe  of 
the  same  diameter  throughout  its  whole  length.  It 
is  provided  with  a  trap  between  the  house  and  the 
sewer,  so  as  to  prevent  the  escape  of  air  from  the 
sewer  through  the  house-drain  into  the  house.     It  is 


PLUMIUNG   AND    DRAINAGE. 


37» 


also  supplied  with  a  ventilator  opciiin<^  between  the 
house  and  the  trap  for  the  entrance  of  fresh  air. 
The  house-drain  is  extended  for  several  feet  above 
the  roof  of  the  house,  and  its  upper  extremity  is  left 
open  to  favor  a  free  circulation  of  air  throughout  its 
entire  length.  When  constructed  in  this  manner, 
and  with  all  sink  and  water-closet  connections  prop- 
erly trapped,  there  is  no  danger  of  the  escape  into 
the  house  of  any  air  contained  in  the  house-drain  or 
the  street-sewer. 

All  the  connections  of  pipes  entering  the  house- 


FlG.  94. — Method  of  connecting  waste-pipe  witli  house-drain. 


drain  should  do  so  at  an  acute  angle  (Fig.  94),  and 
they  must  be  tight,  so  as  to  prevent  leakage  of  fluids 
or  gases.  This  is  a  point  that  cannot  be  too  rigidly 
observed.  The  principal  danger  from  leaky  joints  is 
not  so  ranch  the  escape  of  gases,  as  the  leakage  of 
liquids  and  their  accumulation  on  the  premises.  In 
fact,  in  modern  dwellings,  where  the  plumbing  has 


372 


DOMESTIC  HYGIENE. 


been  satisfactorily  introduced,  there  is  very  little 
cause  for  apprehension  from  the  so-called  "sewer- 
gas,"  because  in  modern  sewers  and  house-drains 
the  air  contained  therein  is  not  much  more  impure 
than  the  air  of  the  overlying  streets. 

In  the  absence  of  a  general  sewerage  system  the 
house-drain  should  discharge  its  contents  into  a  cess- 
pool. Where  cesspools  are  in  use,  they  should  be 
located  at  such   a  point  and   constructed  in  such  a 


Fig.  95. — Wash-out  closet. 


manner  as  to  avoid  the  contamination  of  neighboring 
wells  or  streams. 

Modern  Bath-rooms  and  Toilet-rooms.  —  The 
general  introduction  of  bath-rooms  and  toilet-rooms 
into  houses  has  followed  the  provision  of  adequate 
water-supplies  and  the  construction  of  sewerage-sys- 
tems. These  factors  have  had  a  beneficial  influence 
upon  the  health  of  the  inhabitants  of  modern  towns. 
The  introduction  of  bath-rooms  and  toilet-rooms  has 
made  it  possible  to  secure  a  much  greater  degree  of 
personal    cleanliness,    and    it    has   brought   about   a 


ri.L'MBINC   AND   J) RA I XAii !■:. 


373 


Fig.  96. — Wash-down  closet. 

marked  reduction  in  diseases  disseminated  through 
sewage-polhited  water. 


Fig.  97. — Closet-flushing  tank. 

The  toilet-rooms  should  be  supplied  with  closets 
of  the  wash-out  or  zvash-doicn  type  (Figs.  95  and  96), 
and  should  be  flushed  by  means  of  a  separate  water- 


374  DOMESTIC  HYGIENE. 

supply  furnished  by  a  small  tank  of  from  two  to  three 
gallons  capacity.  Such  tanks  are  known  as  ' '  water- 
waste  preventers''''  (Fig.  97),  because  the  amount  of 
water  contained  in  them  is  sufficient  efficiently  to 
flush  the  closet  each  time  it  is  used,  and  thus  serves 
to  prevent  the  use  of  excessive  amounts  of  water  for 
such  purposes. 

The  bath-room  should  have  the  floor  and  side  walls 
covered  with  tiling,  so  as  to  be  impervious.  The 
bath-tub  should  be  porcelain-lined  cast  iron,  as  these 
are  durable  and  readily  maintained  in  a  satisfactory 
hygienic  condition.  The  inviting  appearance  of  the 
bath-room  fixtures  will  increase  the  frequency  of  their 
use. 

DISPOSAL  OF  GARBAGE  AND  ASHES. 

The  health  of  the  household  can  be  preserved 
by  the  prompt  removal  of  all  materials  which  may 
serve  as  a  source  of  nuisance  in  the  form  of  disagree- 
able odors  or  of  irritating  dust.  Consequently  provi- 
sion must  be  made  for  the  systematic  removal  of 
garbage  and  ashes. 

Garbage  may  be  disposed  of  in  several  ways  :  It 
may  be  burned  in  the  kitchen-range  if  the  family 
is  small.  In  larger  households  other  means  of  dis- 
posal must  be  provided.  Special  furnaces  have  been 
devised  for  the  consumption  of  garbage.  In  most 
cities  and  towns  the  municipality  provides  regular 
scavengers,  whose  duty  it  is  to  collect  the  garbage  at 
regular  intervals.  Where  this  system  is  in  vogue,  the 
collections  should  be  made  at  least  once  daily  during 
the  summer  months,  and  two  or  three  times  a  week 
during  the  remainder  of  the  year.     Complaints  should 


NUISANCES.  375 

be  made  to  the  proper  officials  if  the  collectors  are 
derelict. 

The  disposal  of  ashes  is  a  question  which  has 
received  the  attention  of  ninnicipal  authorities  to  a 
considerable  extent  and  still  awaits  a  satisfactory 
solution.  The  injurious  effects  of  allowing  ashes  to 
accunnilate  on  the  premises  are  generally  recognized, 
but  their  satisfactory  removal  has  given  rise  to  a  great 
deal  of  discussion.  For  hygienic  reasons  the  ashes 
should  be  removed  at  short  intervals, — once  or  twice  a 
week, — and  in  such  a  manner  as  to  prevent  the  produc- 
tion of  dust  or  the  dissemination  of  litter.  To  over- 
come the  latter  factor,  it  would  be  preferable  to  provide 
separate  collectors  for  waste-paper  and  refuse  of  like 
nature,  so  as  to  prevent  their  admixture  with  ashes. 
The  dissemination  of  dust  arising  from  the  careless 
transference  of  ashes  from  boxes  and  barrels  to  the 
carts  may  be  overcome  by  dampening  the  ashes  a 
short  time  before  the  collector  makes  his  rounds. 

NUISANCES. 

Under  nuisances  we  may  class  such  disturbances  as 
foul  odors,  noxious  fumes,  loud  noises,  dust,  smoke, 
and  soot.  Nuisances  may  not  be  directty  detrimental 
to  health,  but  they  are  indirectly  injurious  in  that 
they  engender  discomfort  and  annoyance.  Usually, 
these  factors  arise  outside  the  home,  and  are,  therefore, 
beyond  individual  control  ;  this  is  especially  the  case 
with  noxious  fumes  arising  from  certain  manufactur- 
ing industries,  the  loud  noises  of  cities  resulting  from 
traffic  over  rough  pavements,  the  shriek  of  factory 
and  locomotive  whistles,  and  the  tolling  of  bells. 

Foul   odors  mav  arise  within  the  house  throueh 


376  DOMESTIC  HYGIENE. 

neglect  of  proper  cleanliness  of  cellars,  sinks,  drains, 
and  toilet-rooms.  The  odors  arising  from  these  places 
are  best  controlled  by  strict  cleanliness.  The  use  of 
various  deodorants  for  their  removal  merely  substitutes 
one  odor  for  another,  thus  masking  the  odor  without 
really  removing  it. 

The  noxious  fumes  arising  from  certain  manufac- 
turing establishments  are  sometimes  difficult  to  con- 
trol. Industries  in  which  the  generation  of  such 
fumes  cannot  be  obviated  should  never  be  located  in 
the  residential  portion  of  a  town,  but  should  be  so 
located  as  to  avoid  becoming  a  nuisance,  preferably  in 
the  outskirts  of  the  town. 

The  noises  of  our  modern  cities  are  of  such  a 
nature  in  general  that  many  of  them,  as  the  blow- 
ing of  steam  whistles  and  the  tolling  of  bells,  could 
be  avoided.  These  could  be  reduced  to  a  mini- 
mum, and  in  many  instances  they  could  be  dispensed 
with  entirely.  The  rumbling  of  trains,  trolleys,  and 
the  heavy  traffic  on  the  streets,  while  not  injurious, 
and  frequently  passed  without  notice  by  the  well,  are 
a  source  of  great  annoyance  to  the  sick.  Smooth 
pavements  aid  in  reducing  the  noise  from  street  traffic, 
and  the  more  general  introduction  of  self-propelling 
vehicles  will  also  serve  to  diminish  this  source  of 
annoyance.  The  transference  of  the  surface  street- 
railways  to  subways,  although  probably  a  long  way 
off,  will  be  an  important  measure  in  affording  relief 
from  this  form  of  nuisance. 

The  dust  of  city  streets  is  not  only  a  nuisance,  but 
a  direct  evil.  It  serves  to  distribute  the  pathogenic 
bacteria  which  are  deposited  on  streets  and  pavements 
by  promiscuous  expectoration,  as  well  as  in  the  dis- 


NUISANCES.  377 

semination  of  the  equally  objectionable  horsc-nianure. 
The  advent  of  the  trolley  car  has  brought  into  opera- 
tion a  different  and  equally  dan<^erous  form  of  dust 
in  the  nature  oi Jhie  saiid-particlcs.^  resultiuL;-  frcjui  the 
pulverization  of  the  coarse  sand  used  on  wet  and 
slippery  rails.  Aside  from  the  injury  to  the  eyes, 
these  sand-particles  produce  irritation  of  the  throat 
and  lungs,  and  hence  lead  to  a  lowered  vitality  of  the 
mucous  membrane  lining  the  respiratory  tract,  thus 
paving  the  way  for  subsequent  infection.  There  is 
strong  ground  for  the  opinion  that  the  marked  increase 
in  recent  years  of  diseases  of  the  respiratory  tract, 
especially  of  pneumonia,  is  attributable  to  the  influ- 
ence of  dust  of  this  nature. 

The  removal  of  these  nuisances  will  go  far  toward 
rendering  our  homes  more  healthful.  The  enforce- 
ment of  laws  against  promiscuous  expectoration  in 
public  places,  the  more  efficient  cleansing  of  our  city 
streets  (not  the  perfunctory  cleansing  in  vogue  at  the 
present  time,  which  is  attended  with  the  distribution 
of  clouds  of  dust  along  the  course  of  the  street-clean- 
ing gang,  but  the  systematic  flushing  and  cleansing 
of  the  streets  in  such  a  manner  as  to  avoid  raising 
dust  and  at  such  a  time  as  not  to  interfere  with  traffic), 
and  the  introduction  of  underground  railways,  will 
serve  to  overcome  in  large  part  the  discomfort  and 
danger  from  the  dust  generated  upon  the  streets. 

The  smoke-  and  soot-nuisance  is  one  that  can  be 
overcome  to  a  great  extent  if  the  proper  measures  are 
introduced.  For  those  who  live  near  lines  of  steam 
railroads  or  large  manufacturing  establishments,  the 
smoke  and  soot  generated  are  sources  of  great  annoy- 
ance.    This  is  especially  the  case  where  bituminous 


378  DOMESTIC  HYGIENE. 

coal  is  used.  Oil,  when  used  as  fuel,  also  gives  rise 
to  the  production  of  smoke  and  soot.  Devices  for  the 
consumption  of  the  smoke  by  the  fire  under  the  boiler 
have  been  constructed.  These  serve  to  remove  the 
greater  portion  of  the  smoke  and  soot,  but  are  not  in 
general  use  because  they  increase  the  first  cost  of  the 
machinery  and  interfere  somewhat  with  the  efficiency 
of  the  engine.  This  problem  still  awaits  a  solution 
which  shall  be  applicable  under  all  conditions.  The 
more  general  utilization  of  gas  and  electricity  will 
serve  to  eradicate  the  evil  in  some  instances. 

HOUSE=CLEANINQ. 

In  order  to  understand  what  is  meant  by  the  term 
"house-cleaning,"  it  will  be  necessary  to  define  the 
word  clean  in  its  hygienic  sense.  The  ordinary  con- 
ception of  the  word  clean  is  quite  different  from  the 
chemist's  conception  of  the  word.  To  be  chemically 
clean,  an  object  must  be  free  from  everything  that 
might  interfere  with  or  vitiate  a  chemic  analysis. 
The  sanitarian's  conception  of  the  word  clean  is, 
however,  quite  different  from  the  chemist's,  as  well 
as  from  the  ordinary  conception  of  the  meaning  of 
the  word.  From  a  hygienic  standpoint  cleanliness 
means  the  absence  of  the  specific  causes  of  disease. 
Looking  at  the  subject  from  this  standpoint,  house- 
cleaning  signifies  the  removal  of  all  factors  which  are 
concerned  in  the  propagation  or  dissemination  of  dis- 
ease. 

While  it  is  evident  that  in  actual  practice  we  rarely 
attain  the  ideal,  it  is  essential,  nevertheless,  that  the 
ideal  should  always  be  before  us  so  that  we  may 
approach  it  as  nearly  as  may  be.     In  house-cleaning, 


HOUSE-CLEANING.  3/9 

therefore,  it  should  be  our  aim  to  remove  all  disease- 
proditciug  aoents  froui  the  preuiises,  as  well  as 
those  factors  which  might  teud  toward  the  propaga- 
tion or  dissemination  of  disease.  For  these  reasons 
sweeping  should  not  be  allowed.  All  dust  should 
be  removed  by  means  of  a  dampened  cloth  or 
sponge. 

The  great  purifying  agents  emplo}ed  iu  house- 
cleaning  which  have  been  handed  down  to  us  by  our 
forefathers  are  zvas/ihig-$oda^  soap^  and  Jiot  zvaler^ 
and  these  have  not  been  improved  upon  as  to  siui- 
plicity,  efficiency,  and  cheapness  by  any  of  the 
scientific  discoveries  of  late  years.  Hot  soap-suds 
and  hot  solutions  of  washing-soda  are  efficient  germi- 
cides as  well  as  satisfactory  cleansing  agents,  and 
when  freely  used,  serve  to  remove  many  of  the  dis- 
ease-producing bacteria,  as  well  as  filth,  and  are  all 
that  are  required  to  render  a  house  ''''clean''''  in  the 
hygienic  sense  of  the  word. 

In  cleaning  a  room  occupied  by  persons  suffering 
from  contagious  diseases  these  simple  cleansing  agents 
are  usually  reinforced  by  the  use  of  more  powerful 
germicidal  substances.  Such  a  room  should  first  be 
disinfected  by  means  oi  formaldehyde  applied  either 
by  means  of  a  spraying  apparatus  or  ii\  the  form  of 
gas  generated  in  a  special  apparatus  (Fig.  98).  After 
the  room  has  been  disinfected  by  one  of  these 
methods,  it  should  be  cleaned  by  the  free  use  of  soap 
and  hot  soda  solution. 

Washing  and  Laundering. — Under  ordinary  con- 
ditions the  laundering  of  clothing  has  but  little 
hygienic  interest  when  the  work  is  done  at  home. 
When  cases  of  infectious  diseases  occur  in  the  house- 


38o 


DOMESTIC  HYGIENE. 


hold,  the  clothing  of  the  sick  persons  should  never 
be  laundered  with  those  of  the  remainder  of  the 
family.  The  clothing  of  the  sick  should  be  placed 
into  a  receptacle  containing  water  and  some  anti- 
septic, such  as  carbol  soap,  before  it  is  removed  from 
the  sick-room.  When  moistened  in  this  manner,  it 
may  be  removed  from  the  sick-room,  and  after  stand- 
ing in  the  antiseptic  solution  for 
,,;y!^  several  hours,  may  be  washed  in 
the  ordinary  manner. 

Clothes-cleaning.  — Articles 
of  wearing  apparel  and  bed- 
clothing  that  cannot  be  cleansed 
by  washing  require  cleansing  by 
other  methods.  When  such  ar- 
ticles have  been  exposed  to  in- 
fection, they  should  be  disin- 
fected by  steam  or  by  means  of 
formaldehyd  gas.  Steam-disin- 
fection requires  a  special  appa- 
ratus, and  consequently  this 
cannot  be  carried  out  in  the 
home.  Disinfection  by  means 
of  formaldehyd  gas  may  be  ac- 
complished in  the  home.  This 
may  be  done  in  several  different 
ways,  as  by  spraying  the  articles  with  a  solution  of 
formaldehyd,  or  they  may  be  placed  in  a  large  closet 
which  can  be  rendered  air-tight  and  the  formaldehyd 
gas  generated  in  the  closet  with  a  Sobering  lamp,  or 
the  gas  may  be  generated  in  an  apparatus  such  as 
that  represented  in  Fig.  98  and  conducted  into  the 
closet  through   the  keyhole.     The  last  is  the   safer 


rormaldehyd  gas 
regenerator. 


I'oon  AND  nii'/ri'/rics.  381 

method,   as   the    apparatus   is  iiiulcr  control   and   all 
danger  from  hrc  is  avoided. 

Woolen  clothes,  blankets,  bed-spreads,  and  furs 
should  be  cleansed  at  stated  intervals.  Besides  the 
disinfection  just  described,  such  cleansing  operations 
should  consist  of  measures  directed  toward  the  re- 
moval of  grease  and  filth.  Simple  airing  is  insuf- 
ficient for  satisfactory  cleansing.  Exposure  to  fresh 
air  and  sunshine  is  of  great  service  in  purifying  such 
articles,  but  fails  to  remove  grease-spots.  The  latter 
should  be  removed  by  means  of  naphtha,  benzin,  or 
gasolin.  Dirt  and  grease  are  freely  soluble  in  those 
fluids,  and  they  may  be  applied  to  delicate  fabrics 
without  detriment.  These  cleansing  fluids  may  be 
applied  with  a  sponge  or  cloth,  or  the  articles  may  be 
immersed  in  the  fluids.  After  having  been  cleansed 
in  this  manner  the  articles  must  be  exposed  to  the  air 
for  some  time  to  dry  and  allow  the  cleansing  fluids 
to  evaporate.  After  aeration  for  a  da}'  all  odor  of 
the  cleansing  fluids  will  have  disappeared,  and  the 
articles  are  ready  to  be  pressed  with  a  hot  sad-iron. 
When  cleansed  by  this  method  and  properly  pressed 
afterward,  the  articles  will  appear  almost  like  new 
and  show  no  trace  of  the  manipulation  given  them. 
It  is  necessary  to  be  extremely  cautions  in  the  use  of 
all  these  cleansing  fluids,  as  the}'  are  highly  inflam- 
mable. The  cleansing  operation  should,  therefore, 
always  be  performed  in  the  open  air,  or  at  least  in  a 
room  in  which  there  is  no  light  or  fire. 

FOOD   AND  DIETETICS. 

The  health  of  the  household  is  dependent  to  a  great 
extent  upon  the  nature,  quality,  and  quantity  of  the 


382  DOMESTIC  HYGIENE. 

food-supply,  as  well  as  upon  the  manner  in  which  the 
food  is  prepared.  "Food  is  that  which,  when  taken 
into  the  body,  builds  up  its  tissues  and  keeps  them  in 
repair,  or  which  is  consumed  in  the  body  to  yield 
energy  in  the  form  of  heat  to  keep  it  warm  and  create 
strength  for  its  work." 

All  the  various  elements  and  chemic  combinations 
of  which  the  body  is  composed  must  be  supplied  in 
the  food  in  order  that  it  may  perform  its  normal  func- 
tions and  obtain  energy  for  the  varied  life-activities. 
A  man  of  average  weight  and  activity  takes  about 
325  grams  of  dry  solid  matter  and  from  1500  to 
2000  grams  of  water  by  the  mouth,  and  about  550 
grams  of  oxygen  through  the  lungs  each  day.  The 
solid  matter  taken  as  food  should  be  composed  of 
proteids  or  nitrogenous  organic  matter,  of  fats,  and 
of  carbohydrates.  (See  page  34.)  A  constant  diet 
containing  excessive  amounts  of  any  of  the  three 
elementary  constituents,  with  or  without  deficiency 
of  one  or  both  of  the  other  constituents,  will  in  time 
prove  injurious  to  health.  In  order  to  obtain  the 
relative  proportions  of  the  elementary  constituents 
required  for  nutrition  we  resort  to  a  mixed  diet.  A 
deficiency  in  the  elementary  constituents  of  the 
food  for  a  brief  period  is  readily  equalized  by  varia- 
tion in  the  diet  on  different  days  of  the  week.  Custom 
has  served  to  bring  about  a  selection  of  a  dietary 
which  generally  meets  the  requirements  of  the  body. 

Nutritive  Value  and  Cost  of  Food. — The  follow- 
ing table  (Table  A.)  shows  the  relative  proportions 


FOOD  AND   DIETETICS. 


3<^3 


Table  a. — Nittritive  Value  and  Cost  of  Food  al 
Ordinary  Prices. 


Food  Matekials  as 
pukchaseu 


Beef,  sirloin 

Beef,  round 

Beef,  neclc 

Mutton,  leg 

Ham,  smoked 

Salt  pork 

Codfish,  fresh 

Codfish,  dried  salt  .  .  . 
Mackerel,  salt  .... 
Oysters,  25  cents  a  quart 
Eggs,  25  cents  a  dozen  . 
Milk,  8  cents  a  quart  .  . 
Cheese,  whole  milk  .  . 
Cheese,  skimmed  milk 
Butter,  25  cents  a  pound 
Sugar,  5  cents  a  pound     . 

Wheat  flour 

Wheat  bread 

Oatmeal 

Beans 

Potatoes,  60  cents  a  bushel 


a." 

Twenty-five  cents  w 

11  pay  foi 

- 

■0  „• 
0  j5 

Nutrients. 

Total. 

Protein. 

Fats. 

Carbo- 
hydrat's 

Grams. 

Grams 

Grams. 

Grams. 

Grams 

25 

500 

'55 

75 

So 

16 

780 

235 

140 

95 

8 

1565 

465 

245 

220 

20 

625 

190 

95 

95 

16 

•      780 

385 

i'5 

270 

10 

1250 

1045 

10 

1035 

10 

1250 

135 

8 

.565 

255 

250 

5 

10 

1250 

370 

185 

185 

12.5 

lOOO 

120 

65 

IS 

40 

14  7 

850 

190 

85 

4 

3125 

385 

"5 

125 

145 

'5 

835 

545 

235 

295 

15 

10 

1250 

675 

480 

85 

no 

25 

500 

430 

5 

425 

5 

2500 

2445 

2445 

2-5 

5000 

4350 

550 

55 

3745 

5 

2500 

1670 

220 

40 

1410 

5 

2500 

2260 

370 

180 

1710 

5 

2500 

2HO 

580 

50 

1480 

I 

12,500 

2135 

225 

10 

1900 

Fuel 
value. 


Calories. 

970 
1335 
2755 
1 170 
2705 
8775 

510 

985 
2275 

520 
i"5 
2030 
3455 
2910 
3615 
9100 
16,450 
6400 
9225 
8075 
8000 


of  the  elementary  food-constituents  in  some  of  the 
more  common  food-substances  with  the  quantity  that 
can  be  purchased  for  twenty-five  cents,  as  well  as  the 
amount  of  energy  that  may  be  derived  therefrom. 


Table  B. — Analyses  of  Cereals  and  Lcgnminosce. 

Composition  of  the  Cereals. 


Cereal. 

No.  of 
anal- 
yses. 

Nitrogen- 
ous sub- 
stances. 

Fat. 

Nitrogen- 
free  extrac- 
tives. 

Cellu- 
lose. 

Ash. 

Nitro- 
gen. 

Wheat.    .    . 
Rye,  winter 
Barley .    .    . 
Oats  .... 

Corn,  flint    . 
Rice     .    .    . 

1358 
173 
766 

377 
80 
10 

Per  ct. 
13.89 
12.48 
11.24 
12.13 
11.74 
7.00 

Per  ct. 
2.20 

1-77 
1-93 
4-99 

4.78 

2.00 

Per  ct. 

79-75 
81.04 

77.24 
66.41 
79.20 
84.76 

Per  ct. 
2.19 
1. 78 

4-95 

lo.i^S 

1.67 

4.00 

Per  ct. 
1.97 
2.06 
2.42 

3.29 
1.40 
1.16 

Per  ct. 
2.22 
2.00 
1.79 
1.04 

1.88 

1. 12 

384 


DOMESTIC  HYGIENE. 


Composition 

of  the 

LeguminoscE. 

No.  of 
anal- 
yses. 

Nitrogen- 
ous sub- 
stances. 

Fat. 

Nitrogen- 
free  extrac- 
tives. 

Cellu- 
lose. 

Ash. 

Nitro- 
gen.- 

Beans   .    .    . 
Peas      .    .    . 

63 

72 

Per  ct. 
29.26 
26.39 

Per  ct. 
1.68 

1-39 

Per  ct. 
55.86 
61.21 

Per  ct. 
8.06 
5.68 

Per  ct. 
2.68 

Per  ct. 
4.68 
4-3° 

Table  B  shows  the  composition  of  the  more  com- 
mon cereals  and  legnminosse  used  for  food  based  upon 
a  large  number  of  analyses.  This  table  shows  that 
these  food-materials  contain  the  elementary  food-con- 
stituents, expressed  as  nitrogenous  substances,  fat, 
and  nitrogen-free  extractives.  The  relative  amount 
of  these  elementary  constituents  is  such  that  exces- 
sive quantities  of  refuse  matter  and  of  carbohydrates 
must  be  taken  to  obtain  the  required  amounts  of  pro- 
teids.  This  is  the  chief  source  of  dissatisfaction  with 
a  true  vegetarian  diet — that  is,  a  diet  entirely  of 
veg-etable  orio-in. 

Cooking. — Aside  from  the  composition  of  foods,  the 
modes  of  preparation  are  of  the  greatest  hygienic 
importance.  Cooking  has  two  principal  effects  on 
food-materials  :  it  softens  the  food  so  as  to  render  it 
easier  of  mastication  and  digestion,  and  it  also  renders 
it  more  palatable.  In  addition  to  these  alterations 
cooking  also  serves  to  destroy  all  bacteria  that  may 
be  lodged  in  or  upon  the  food,  and  in  this  manner 
renders  it  free  from  danger  to  health. 

The  manner  of  cooking  has  a  marked  influence 
upon  the  digestibility  of  meats.  The  common  modes 
of  preparing  meats  are  roasting,  broiling,  boiling,  and 
frying.  Roasted  and  broiled  meats  retain  a  large 
proportion  of  their  juices,   and  are,   therefore,   more 


loon   AND    /)//'.'/ 7'.  7 VCS.  3S5 

palatable  as  well  as  more  nuliiti(Mis.  I>()ilin,ij;  exlraels 
the  juices  from  the  meat  and  conse(|iiently  alters  their 
nutritive  qualities  as  well  as  their  ])alataljility.  Fry- 
ing in  fats  and  oils  causes  the  meat  to  be  unusually 
rich  in  fat,  and,  in  consequence,  more  difficult  of 
digestion. 

The  purity  of  the  food-materials  is  of  equal 
importance  with  their  quality  and  quantity.  Foods 
may  be  adulterated  in  several  different  ways,  as  by 
the  abstraction  of  some  of  the  most  valuable  ingre- 
dients and  the  substitution  of  inferior  or  inert  sub- 
stances, and  by  the  addition  of  various  preservatives 
intended  to  prevent  or  retard  decomposition. 

Milk^  for  instance,  may  be  adulterated  by  the 
abstraction  of  cream,  the  addition  of  water,  or  the 
addition  of  preservatives,  such  as  formaldehyd  or 
borax,  and  the  addition  of  coloring-matters  to  mask 
the  abstraction  of  cream.  Preserved  fruits  are  com- 
monly adulterated  by  the  addition  of  glucose,  and 
jellies  are  frequently  found  on  the  market  that  are 
composed  entirely  of  artificial  materials,  as  glucose, 
coloring-matters,  etc.  Baki7ig-pozvders  are  adulter- 
ated by  the  substitution  of  alum  for  more  expensive 
ingredients.  Butter  is  adulterated  by  the  addition  or 
substitution  of  other  fats  of  vegetable  and  animal 
origin.  Olive  oil  is  adulterated  by  the  substitution 
of  the  cheaper  cotton-seed  oil. 

Food  may  cause  infectious  diseases  from  the 
presence  in  it  of  specific  bacteria  or  parasites.  Alilk 
may  contain  tubercle  bacilli  when  derived  from  tuber- 
cular cows,  or  it  may  contain  pus-producing  organisms 
(streptococci)  when  there  is  catarrh  or  inflammation 
of  the  udder.     Milk  may  serve  as  the  carrier  of  other 

25 


386  DOMESTIC  HYGIENE. 

disease-producing  bacteria  by  tlie  accidental  entrance 
of  such  organisms  as  the  bacillus  of  diphtheria,  the 
bacillus  of  typhoid  fever,  the  bacillus  of  dysentery, 
or  the  cholera  organisms.  These  organisms  usually 
gain  access  to  milk  by  the  addition  of  polluted  water 
or  by  rinsing  and  washing  the  containers  with  such 
polluted  water.  Milk  may  also  serve  as  the  carrier 
of  scarlet  fever  when  this  disease  prevails  in  the 
family  of  the  milkman  or  dairyman.  Butter  may 
serve  as  the  carrier  of  disease  in  much  the  same  way 
as  milk. 

Meat  may  contain  the  organisms  of  tuberculosis  as 
well  as  the  ova  and  larvae  of  animal  parasites,  as 
trichina,  cysticercus,  etc.  For  these  reasons  meat 
should  never  be  eaten  in  the  raw  state.  Green  vege- 
tables may  serve  as  the  carriers  of  disease  when  they 
are  raised  in  ground  fertilized  with  night-soil.  Let- 
tuce may  also  convey  typhoid  fever  or  the  ova  of 
animal  parasites  when  raised  on  such  ground.  Oysters 
are  now  recognized  as  frequent  -carriers  of  the  bacillus 
of  typhoid  fever,  on  account  of  having  been  freshened 
in  sewage-polluted  streams. 

Inspection  of  Foods. — The  dangers  from  infected 
meat  and  milk  and  from  adulterated  foods  in  general 
can  be  overcome  only  by  the  most  rigid  sanitary 
inspection.  These  are  conditions  which  the  individ- 
ual cannot  control  altogether. 

The  inspection  of  meats  should  include  not  only 
the  routine  slaughter-house  inspection,  but  should  also 
include  rigid  inspection  of  the  meat  exposed  for  sale 
in  markets  and  shops.  A  great  deal  of  the  danger 
arising  from  the  consumption  of  diseased  and  putrid 
meat  can  be  avoided  by  such    inspection.     In    this 


FOOD  AND  DIETETICS.  387 

connection  a  committee  of  prominent  physicians  and 
veterinarians  has  recently  made  the  followinjj^  recom- 
mendations to  the  health  authorities  of  Philadelphia  : 

"First:  All  meat  inspected  by  the  meat-inspector  should 
be  stamped. 

"  Second  :  The  hours  for  slaughtering  should  be  regulated, 
and  butchers  should  be  prohibited  from  killing  animals  at 
times  other  than  those  fixed. 

"Third:  All  slaughter-houses  should  be  visited  by  the 
meat-inspectors  during  the  hours  of  slaughtering,  and  all  the 
carcasses  should  be  examined,  and  those  found  to  be  in  a  con- 
dition suitable  for  food  should  be  stamped. 

"  Fourth  :  Beef  prepared  in  the  surrounding  country  and 
brought  into  the  city  in  wagons  should  be  brought  in  only  at 
certain  specified  times,  and  before  unloading  the  wagon  should 
pass  a  certain  inspection-point  where  the  meat  could  be  ex- 
amined by  an  inspector  stationed  for  this  purpose,  and  stamped 
if  found  to  be  in  sound  condition. 

"  Fifth  :  The  meat-inspection  force  should  be  increased  by 
the  addition  of  a  sufficient  number  of  veterinarians. 

"  Sixth  :  Sanitary  regulations  should  be  established  govern- 
ing certain  features  of  the  construction,  fittings,  and  care  of 
slaughter-houses,  and  all  slaughter-houses  falling  below  a  rea- 
sonable standard  should  be  proceeded  against  as  a  nuisance." 

The  committee  also  believes  that  there  should  be 
fewer  slaughter-houses  and  more  inspectors.  In  Paris 
there  are  70  inspectors  and  only  2  abattoirs.  In  Ber- 
lin there  are  150  inspectors  and  only  i  abattoir.  In 
Philadelphia  there  are  more  than  100  slaughter-houses 
and  but  5  inspectors. 

The  inspection  of  milk  as  practised  in  most  muni- 
cipalities fails  to  accomplish  all  that  might  be  accom- 
plished in  this  direction.  The  municipal  inspectors 
rarely  possess  the  authority  to  extend  their  supervision 
of  the  milk-supply  beyond  the  limits  of  the  muni- 
cipality.    Systematic  inspection  of  dairies  and  milk- 


388  DOMESTIC  HYGIENE. 

shops  as  to  manner  of  production  and  storing  of  milk 
will  accomplish  a  great  deal.  The  licensing  of  all 
milk-dealers  has  served  a  useful  purpose.  The  proper 
care  of  milk  in  the  household  is  often  neglected. 
Milk  should  be  purchased  in  sterilized  bottles  and 
should  be  removed  from  these  containers  only  when 
it  is  to  be  used.  Milk  should  be  placed  on  ice  as  soon 
as  delivered,  so  as  to  prevent  the  too  rapid  develop- 
ment of  bacteria  in  it. 

The  recent  suggestions  of  a  Medical  Milk  Com- 
mission appointed  by  the  Director  of  Public  Health 
of  Philadelphia  are  as  follows  : 

1.  That  all  milk-sellers  be  required  to  obtain  a  license,  and 
that  such  license  be  granted  free  of  charge. 

2.  That  no  license  be  issued  unless  the  dealer  is  willing  to 
state  the  source  of  his  supply,  and  to  give  satisfactory  evidence 
that  the  producer  from  whom  he  receives  his  milk  maintains 
his  herd  and  premises  up  to  the  standard  prescribed  by  the 
Department  of  Public  Health ;  observance  of  such  standard 
to  be  determined  by  periodic  inspections  under  the  direction 
of  this  same  department. 

3.  That  the  standard  to  be  established  should  correspond 
closely  or  exactly  to  the  list  of  fifty  dairy  rules  recommended 
by  the  Bureau  of  Animal  Industry  of  the  United  States 
Department  of  Agriculture. 

4.  That  dealers  be  required  to  remove  all  milk  from  the 
transportation  trains  immediately  upon  their  arrival,  unless  in 
refrigerator  cars,  and  to  deliver  the  milk  of  the  morning  and 
previous  evening  on  the  day  of  its  arrival,  unless  kept  iced. 

5.  That  dealers  be  required  to  have  a  special  milk-room  so 
situated  in  relation  to  their  houses  as  not  to  be  a  thorough- 
fare. That  its  walls  shall  be  tiled  or  painted  with  a  glazed 
paint ;  that  its  floors  be  made  of  hard  wood,  cement,  or  other 
composition,  or  that  they  shall  be  covered  with  linoleum; 
that  the  room  shall  be  well  ventilated  and  kept  thoroughly 
clean. 

6.  That  it  be  required  that  all  milk-wagons  be  thoroughly 
cleansed  after  each  delivery,  and  that  they  be  so  constructed 


CAUSES  AND    TA'A A'SM/SS/ON  OF  J)ISEASE.       3<S9 

that  thorough  cleansing  is  jjossiblc.  That  all  utensils,  such 
as  dippers,  etc.,  carried  on  mi  Ik- wagons,  when  not  in  use,  be 
kept  in  separate  clean  cans. 

7.  That  no  dealer  or  producer  be  permitted  to  deliver  milk 
in  bottles  who  has  not  on  his  premises  satisfactory  a[;pliances 
for  the  proper  cleansing  and  sterilization  of  bottles  and  who 
does  not  properly  use  them. 

8.  That  no  dealer  be  permitted  to  fill  bottles  outside  of  his 
own  milk-room.  That  dealers  should  be  required  thoroughly 
to  cleanse  and  scald  all  milk-cans  before  returning  them  to  the 
producer. 

In  conclusion,  the  Commission  says  : 

"  In  addition  to  the  tests  which  are  at  present  applied  by 
the  Inspectors  of  Milk  we  would  suggest  that,  in  order  to 
obtain  some  idea  of  the  bacterial  contents  of  the  milk,  the 
degree  of  acidity  of  the  milk  be  determined  and  that  all  milk 
showing  an  acidity  of  more  than  0.2  per  cent,  be  condemned. 
That  an  examination  by  sedimentation  be  made  to  determine 
the  amount  of  dirt  per  cent.,  and  if  found  in  more  than  a 
minimum  quantity,  that  such  milk  be  condemned. 

"Any  dairyman  or  dealer  who  is  incapable  of  meeting  such 
requirements  should  not  be  permitted  to  produce  or  sell  milk. 
While  we  realize  that  a  more  rigid  standard  would  be  desirable 
from  the  standpoint  of  the  public  health,  we  recognize  the  im- 
practicability of  attempting  to  establish  such  standard  at  the 
present  time.  We  deem  it  advisable  to  approach  the  higher 
standard  by  gradual  stages,  insisting  upon  a  strict  enforce- 
ment of  the  moderate  suggestions  recommended." 

CAUSES   AND  TRANSMISSION   OF   DISEASE. 

The  physical  causes  of  disease  are  such  physical 
agents  as  heat  or  cold,  excessive  or  deficient  humidity 
of  the  air,  contusions,  wounds,  accidents,  dust,  and 
winds.  Changes  in  barometric  pressure,  as  in  balloon- 
ascensions  or  in  mountain-climbing,  where  the  air  is 
rarefied,  and  in  work  in  deep  mines,  in  caissons,  or 
submarine  operations,  where  the  atmospheric  pressure 
is  increased,  may  proye  injurious. 

The    vital    causes   of    disease    are    the    diflferent 


590  DOMESTIC  HYGIENE. 

species  of  bacteria  and  vegetable  and  animal  para- 
sites. The  bacteria  cause  disease  by  the  production 
of  virulent  poisons  which  are  destructive  to  the 
blood-cells  and  tissue-cells.  The  animal  and  vege- 
table parasites  cause  disease  through  the  destruction 
of  the  blood-cells  and  tissue-cells,  by  the  absorption 
of  nutritive  materials,  and  by  the  obstruction  of  im- 
portant tissues  and  organs. 

The  chemic  causes  of  disease  are  the  numerous 
chemic  substances  which  are  destructive  to  the  tissues 
with  which  they  come  in  contact. 

Transmission  of  tine  infectious  diseases  may  be 
effected  in  a  variety  of  ways  :  By  drinking-water, 
food,  air,  soil,  wounds,  direct  and  indirect  contact, 
and  through  the  agency  of  insects.  The  diseases 
which  are  transmitted  by  drinking-water  ajid  food 
are  those  which  have  their  primary  seat  in  the  diges- 
tive tract.  The  diseases  which  are  transmitted 
through  the  air  are  those  affecting  the  respiratory 
tract.  The  eruptive  fevers  may  also  be  transmitted 
through  the  air.  The  diseases  which  are  most  likely 
to  be  transmitted  through  the  soil  are  tetanus  and 
malignant  edema,  and  the  organisms  causing  these 
diseases  are  usually  introduced  into  the  body  through 
punctured  or  incised  wounds  or  through  abrasion. 
Many  diseases  are  probably  largely  transmitted  by 
contact.^  direct  or  indirect.  Indirect  contact  may  take 
place  through  the  agency  of  anything  that  has  been 
used  or  handled  by  the  person  suffering  from  the 
disease,  as  clothing,  cups,  napkins,  handkerchiefs, 
money,  books,  etc. 

Insects  and  vermin  may  serve  to  transmit  disease 
either  directly  or  indirectly.     Examples  of  the  direct 


CAUSES  AN  J)    TRANSMISSJON   OF  DISEASE.       39 1 

transmission  of  the  organisms  of  disease  by  means  of 
insects  are  the  transmission  of  malaria,  yellow  fever, 
and  filariasis  through  the  agency  of  certain  species 
of  )>iosqidtos^  and  the  transmission  of  relapsing  fever 
through  the  agency  of  bedbugs.  The  indirect  trans- 
mission of  disease  by  insects  occurs  when  the  insects, 
such  as  flies,  cockroaches^  and  bedbugs,  become  con- 
taminated with  the  germs  of  disease,  and  carry  the 
infective  agents  on  their  bodies  to  food  or  to  other 
persons.  The  influence  oi  Jiics  in  the  dissemination 
of  disease  had  not  been  fully  appreciated  until  a  few 
years  ago.  Flies  alight  on  all  kinds  of  filth  and  soil 
their  wings  and  feet  and  may  subsequently  carry  the 
disease-producing  bacteria  to  food-materials.  In  this 
manner  disease  may  be  disseminated  over  consid- 
erable areas.  Consequently,  for  distinct  sanitary 
reasons,  flies,  as  well  as  mosquitoes,  should  be  ex- 
cluded from  houses  by  means  of  mosquito-netting. 
Similarly,  fleas  should  also  be  destroyed  or  excluded, 
as  they  are  thought  to  be  directly  or  indirectly  instru- 
mental in  the  transmission  of  plague  and  of  the 
"spotted  fever"  of  Idaho  and  Montana.  Rats  are 
believed  to  be  concerned  in  the  dissemination  of 
plague. 

All  vermin  should,  therefore,  be  excluded  from 
houses,  and  when  they  have  gained  access,  they  should 
be  exterminated  as  speedily  as  possible.  Vermin  of  this 
character  are  found  most  frequently  in  filthy  loca- 
tions, and  hence  cleanliness  is  the  best  safeguard 
against  vermin  as  well  as  against  the  diseases  which 
they  may  disseminate. 

The  Prevention  of  Disease  by  Isolation  and 
Disinfection.— By  means   of  isolation   the  infective 


392  DOMESTIC  HYGIENE. 

materials  are  confined  to  the  immediate  vicinity  of 
the  23atient,  and  by  means  of  disinfection,  the  infective 
materials  are  rendered  harmless.  The  discovery  of 
the  specific  canses  of  disease  and  the  avenues  by 
which  they  are  thrown  off  from  the  body  have  simpli- 
fied our  efforts  to  limit  the  dissemination  of  disease 
through  disinfection. 

In  the  diseases  of  the  alimentary  tract  the  infective 
agents  are  thrown  off  with  the  intestinal  evacuations 
and  the  urine,  and  it  is  to  these  evacuations  that  we 
must  apply  the  disinfective  materials.  In  diseases  of 
the  respiratory  tract,  as  in  influenza,  pneumonia,  pul- 
monary tuberculosis,  diphtheria,  mumps,  and  whoop- 
ing-cough, the  sputum  contains  the  infective  agents, 
and  must,  therefore,  be  disinfected.  In  these  dis- 
eases the  sputum  should  be  collected  in  sputum-cups 
or  paper  napkins,  which  can  be  disposed  of  by  burn- 
ing them.  In  the  eruptive  fevers  the  infective 
materials  are  believed  to  be  given  off  principally 
through  the  desquamating  epithelium,  and  this  must 
receive  the  disinfecting  materials. 

The  individual  susceptibility  to  infection  varies 
greatly.  The  degree  of  susceptibility  is  dependent 
principally  upon  the  general  physical  condition  of 
the  individual,  upon  his  environment,  and  upon 
hereditary  influences.  A  loivering  of  the  genei'-al 
physical  tone.,  from  whatever  cause,  predisposes  to  in- 
fection. So  long  as  the  physical  condition  of  the 
body  is  maintained  in  the  normal  state,  infection  does 
not  readily  take  place.  It  is  safe  to  assume  that  all  of 
us  are  more  or  less  frequently  exposed  to  different  in- 
fective agents,  which  fail  to  gain  a  foothold  in  our 
bodies  because  of  the  normal  vital  resistance.     En- 


CAUSES  AND    TRANSMISSION  OF  DISEASE.       393 

vironment  plays  an  important  part  in  predisposing  to 
infection.  This  may  operate  by  inducing  a  lowered 
vitality  of  the  body,  as  well  as  by  the  more  frequent 
and  intimate  contact  with  infective  materials  in  places 
that  are  overcrowded,  as  street-cars,  schools,  and 
other  j)ublic  assemblies.  The  influence  of  environ- 
ment is  brought  out  very  well  in  the  investigations 
of  Anders  and  Flick,  of  Philadelphia,  and  Park,  of 
New  York,  on  the  prevalence  of  tuberculosis  in  cer- 
tain houses.  These,  investigations  have  shown  that 
the  disease  is  most  prevalent  in  houses  in  which  pre- 
vious cases  have  occurred.  Heredity  plays  an  im- 
portant role  in  the  individual  susceptibility  to  dis- 
ease. The  peculiar  constitutional  states  which  we 
inherit  predispose  to  special  types  of  infection.  This 
is  seen  in  the  greater  susceptibility  to  certain  diseases 
in  one  family  than  in  another.  The  influence  of 
heredity  is  seen  more  particularly  in  the  prevalence  of 
certain  constitutional  diseases,  although  it  is  believed 
to  be  an  important  factor  in  predisposing  to  diseases 
like  tuberculosis  and  rheumatism. 

Hygiene  of  the  Sick-room. — When  infectious 
disease  appears  in  the  household,  the  patient  should 
be  isolated  in  a  large  airy  room  on  the  upper  floor, 
which  is  removed  as  far  as  possible  from  the  other 
occupants  of  the  house.  The  upper  floor  of  the  house 
is  to  be  preferred,  because  it  is  further  removed  from 
annoyance  by  street-noises  and  street-dust.  All  well 
persons,  with  the  exception  of  the  physician  and 
nurse,  should  be  rigidly  excluded  from  the  room. 
The  other  occupants  of  the  house  should  be  prohibited 
from  attending  any  school  or  other  public  assembly. 
A  moistened  sheet  suspended  in  front  of  the  door  of 


394  DOMESTIC  HYGIENE. 

the  sick-rooin  will  serve  to  arrest  most  of  the  infectious 
dust-particles.  The  room  itself  should  be  furnished 
as  simply  as  possible  ;  all  unnecessary  furniture,  as 
well  as  carpets  and  curtains,  should  be  removed.  No 
sweeping  should  be  allowed  in  such  a  room.  The 
nurse  should  wipe  all  horizontal  surfaces  with  a  damp 
cloth  each  day.  The  clothing  and  bed-clothing  should 
be  placed  in  carbol-soap  solution  before  they  are  re- 
moved from  the  room.  The  sick-room  should  be 
supplied  with  a  gas-stove  and  a  small  boiler,  in  which 
napkins,  eating  utensils,  etc.,  may  be  disinfected  with 
boiling  water  before  removal  from  the  room.  The 
food  that  is  not  consumed  by  the  patient  should  always 
be  burned. 

After  the  recovery  of  the  patient  the  room  should 
be  closed  for  some  hours  to  allow  all  dust-particles  to 
subside.  It  should  then  be  fumigated  or  disinfected, 
after  which  it  may  be  cleaned  in  the  usual  manner 
with  hot  soda  solution,  chlorid-of-linie  solution,  or 
some  of  the  stronger  disinfectants,  as  2  or  3  per  cent, 
carbolic-acid  solution.  All  toys  and  other  articles  of 
little  value  which  have  been  in  the  room  should  be 
wrapped  in  a  sheet  moistened  with  solution  of  chlorid 
of  lime  or  carbolic  acid  and  afterward  burned.  Books 
that  have  been  in  a  sick-room  should  always  be  disin- 
fected before  they  are  again  used.  This  is  usually 
done  by  means  of  formaldehyd  gas. 

House-quarantine  is  instituted  b}^  the  authorities 
of  cities  and  towns  against  a  number  of  infectious 
diseases,  the  custom  varying  somewhat  in  different 
places.  The  diseases  against  which  quarantine  is 
usually  practised  are  :  cholera,  small-pox,  diphtheria, 
diphtheric  croup,   membranous  croup,   scarlet   fever, 


CAUSES  AND    TRANSMISSION  OF  DISEASE.      395 

typhoid  fever,  typhus  fever,  plague,  epidemic  cerebro- 
spinal fever,  relapsing  fever,  and  leprosy.  The  length 
of  time  during  which  quarantine  is  necessary  differs 
with  each  disease  :  in  some,  the  period  is  fixed  arbi- 
trarily ;  in  others,  as  in  diphtheria  and  diphtheritic 
croup,  quarantine  is  maintained  until  cultures  from 
the  patient's  throat  show  the  absence  of  the  specific 
bacteria.  In  the  eruptive  fevers,  as  scarlet  fever  and 
measles,  quarantine  is  continued  until  desquamation 
has  ceased.  Table  C.  shows  the  carriers  of  the  infec- 
tion, the  period  of  incubation,  the  period  of  desqua- 
mation, the  point  of  entrance  of  the  infectious  agent, 
the  excretions  which  are  infective,  the  cause,  the 
special  prophylactic  measures,  and  the  preventive 
measures  of  the  principal  infectious  diseases. 

The  length  of  time  during  which  well  persons 
should  be  detained  in  quarantine  after  exposure  to 
the  different  infectious  diseases  which  might  be  car- 
ried by  them,  is  shown  in  the  following  table  : 

Periods  of  Isolation  of  IVdl  Persons  after  Exposure  to — 
Diseases.  Days. 

Small-pox  » 14- 

Measles      10 

Scarlet  fever 3 

Diphtheria 3 

Cholera lo 

Typhoid  fever 14 

Yellow  fever 5 

Chicken-pox 20 

Mumps 24 

Whooping-cough 21 

This  period  of  detention  varies  in  the  diflferent  dis- 
eases because  of  the  varying  lengths  of  their  respective 
periods  of  incubation.  After  the  period  of  incubation 
for  a  particular  disease  has  passed  and  no  new  cases 


396 


DOMESTIC  HYGIENE. 


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398  DOMESTIC  HYGIENE. 

have  developed,  the  persons  in  quarantine  may  be 
released. 

Special    Precautions  against  Typhoid    Fever. — 

The  following  is  an  open  letter  relative  to  the  preven- 
tion of  typhoid  fever,  issued  to  the  citizens  of  Phila- 
delphia by  the  Bureau  of  Health  : 

Typhoid  fever  is  caused  by  a  tiny  germ  that  gets  into  the 
body  of  the  sick  person,  usually  by  way  of  the  mouth,  and 
that  escapes  from  the  body  with  the  discharges  from  the  body. 

The  discharges  are,  therefore,  to  be  regarded  as  dangerous. 
These  matters  may  easily  be  rendered  harmless  by  scalding 
them  with  boiling  water  or  by  the  use  of  any  of  the  reliable 
disinfectants,  especially  chlorid  of  lime.  Such  matters  should 
always  be  disinfected  before  being  thrown  away. 

When  discharges  from  typhoid  patients  are  thrown  into 
wells  or  strewn  upon  the  ground  or  into  sewers,  the  germs  do 
not  die  at  once,  but  remain  alive  fpr  varying  lengths  of  time, 
and  when  spread  about,  may  cause  an  outbreak  of  the  disease. 

Persons  contract  typhoid  fever  principally  by  swallowing 
germs  that  have  come  from  some  case  of  typhoid  fever ;  some- 
times the  germs  are  conveyed  to  the  mouth  on  soiled  hands. 
This  is  most  frequently  seen  in  the  cases  of  careless  nurses 
who  are  in  attendance  upon  typhoid  patients.  Sometimes 
they  get  into  the  drinking-water,  where  they  may  live  for  a 
time,  and  cause  the  disease  in  those  using  the  water. 

Sometimes  they  get  into  milk  by  way  of  water  that  is  used 
in  washing  the  milk-cans  and  bottles.  When  present  in  milk, 
they  grow  and  multiply  with  great  rapidity,  and  a  number  of 
serious  outbreaks  of  the.  disease  have  been  traced  to  milk  in 
which  these  germs  were  growing. 

Now  and  again  oysters  that  are  kept  in  water  that  is  polluted 
with  sewage  are  also  known,  when  eaten  raw,  to  have  caused 
the  disease.  It  is  also  possible  that  typhoid  fever  is  sometimes 
spread  through  other  food-stuffs  on  which  the  germs  have 
been  by  accident  or  through  carelessness  deposited. 

Fortunately,  the  germ  of  typhoid  fever  is  easily  killed  by 
heat.  If  water  or  milk  containing  living  typhoid  germs  be 
boiled  for  one  minute,  they  are  rendered  free  of  danger, 
as  such  treatment  kills  all  living  germs.  The  cooking  of 
other  foods  robs  them  also  of  all  power  to  cause  typhoid. 


CAUSES  AND    TRANSAHSSlON   O/'   D/SEASlL       399 

When  typhoid  fever  is  present  in  a  neigiiboriiood,  much 
may  be  clone  to  check  its  spread  by  the  use  of  only  boiled 
water  and  milk  and  cooked  foods.  After  water,  milk,  and 
other  food-stuffs  have  been  freed  from  danger  l^y  cooking, 
they  are  to  be  protected  against  the  dust  and  dirt  until  used. 

Special  Precautions  against  Small-pox. — A  val- 
uable circular  relating  to  the  prevention  of  small-pox 
epidemics,  issued  by  the  Bureau  of  Health  of  Phila- 
delphia, reads  as  follows  : 

■  Small-pox  is  one  of  the  most  contagious  of  diseases.  It  is 
probably  contagious  from  the  beginning  to  the  end  of  its 
course. 

The  majority  of  persons  who  have  not  been  successfully 
vaccinated  or  who  have  not  had  small-pox  are  liable  to  con- 
tract it  when  it  is  present  in  the  community. 

Of  persons  who  have  had  the  disease  or  those  who  have 
been  successfully  vaccinated  within  a  period  of  five  years,  only 
a  very  small  number  are  ever  attacked. 

Before  the  beneficial  effects  of  vaccination  were  discovered 
small-pox  was  one  of  the  commonest  of  diseases.  Rich  and 
poor,  high  and  low,  ignorant  and  educated,  were  all  affected. 
In  those  countries  where  vaccination  is  compulsory,  small-pox 
is  to-day  regarded  as  a  medical  curiosity. 

It  is  a  significant  fact  that  of  all  the  cases  of  small-pox 
admitted  to  the  Municipal  Hospital  of  Philadelphia  only  a 
very  small  number  have  been  children  attending  the  public 
schools.  The  reason  for  this  is  that  no  child  is  allowed  to 
enter  the  public  schools  who  has  not  been  vaccinated. 

No  one  should  regard  himself  as  protected  from  small-pox 
until  a  physician  has  i)ronounced  the  vaccination  a  success. 
A  sore  arm  or  the  simple  act  of  vaccination  does  not  neces- 
sarily constitute  protection. 

When  a  case  of  small-pox  occurs,  it  is  for  the  best  interest 
of  the  patient,  the  family,  and  the  county  for  the  patient  to 
be  removed  at  once  to  the  Municipal  Hospital  for  treatment. 
When  for  various  reasons  this  is  not  done,  he  should  be  isolated 
in  a  room  on  the  upper  floor  of  the  dwelling,  located  as  far  as 
possible  from  those  rooms  occupied  by  the  rest  of  the  family. 
The  room  should  be  instantly  cleared  of  all  carpets,  curtains, 
hangings,    and    unnecessary   woolen   goods.      The    furniture 


400  DOMESTIC  HYGIENE. 

should  be  of  the  simplest  possible  description.  The  simpler 
the  furnishing  of  the  room,  the  more  easily  can  successful 
disinfection  be  accomplished  after  recovery  of  the  patient. 

When  the  room  occupied  by  the  small-pox  patient  has  been 
vacated,  the  Board  of  Health  should  be  notified.  The  premises 
will  then  be  disinfected  and  all  articles  of  bed  and  body 
clothing  will  be  removed  to  the  disinfecting  plant,  and,  after 
having  been  rendered  free  from  danger  by  exposure  to  steam, 
will  be  returned  to  the  owner.  This  is  done  without  cost  to 
the  householder  and  without  injury  to  the  articles. 

Under  no  circumstances  should  bed  or  body  clothing  or 
room  hangings  be  taken  from  the  sick-room  to  other  parts  of 
the  house  or  be  shaken  out  of  the  window  until  after  they  have 
been  properly  disinfected.  By  so  doing  th^  disease  is  spread 
through  the  house  or  through  the  neighborhood. 

When  small-pox  has  occurred  in  a  house  and  after  the  sick- 
room has  been  disinfected,  nothing  is  more  useful  in  rendering 
the  premises  free  from  danger  than  a  thorough  scrubbing  of 
walls,  ceilings,  floors,  and  furniture  with  a  hot  solution  of 
common  washing-soda  made  by  mixing  one-half  pound  of 
soda  in  three  gallons  of  boiling  water. 

Persons  renting  houses  in  sections  of  the  city  where  small- 
pox has  been  conspicuously  prevalent  would  do  well  to  inquire 
into  the  health  of  the  family  last  occupying  the  premises. 

Employers  would  do  well  to  insist  that  all  employes  present 
a  physician's  certificate  of  successful  vaccination. 

All  suspicious  eruptions  upon  the  skin  should  be  at  once 
submitted  to  a  physician  for  examination.  In  case  of  doubt 
the  Board  of  Health  stands  ready  to  offer  the  services  of 
physicians  skilled  in  the  recognition  of  small-pox. 

Too  much  stress  cannot  be  laid  upon  the  desirability  of 
prompt  notification  in  connection  with  small-pox.  On  a 
number  of  occasions  the  work  of  the  Board  of  Health  in 
eradicating  the  disease  has  been  seriously  hampered  by  failures 
and  delays  in  carrying  out  this  obligation. 


APPENDIX* 


PULSE,   TEMPERATURE,   AND   RESPIRATION. 

The  pulse,  temperature,  and  respiration  are  called  the 
^^  three  vital  signs  ";  and  it  is  of  advantage  to  every  one  to 
understand  them  and  to  recognize  the  variations  from  normal 
and  their  significance.  They  are  so  closely  connected  that 
whatever  affects  one  generally  affects  the  others. 

The  Pulse. — Each  time  the  heart  contracts,  blood  is 
thrown  into  the  arteries,  distending  them  ;  and  it  is  this  dis- 
tention, or  rising-up  of  the  wall  of  the  artery  at  regular 
intervals,  corresponding  with  the  beatings  of  the  heart,  that 
is  called  "  the  pulse."  In  feeling  the  pulse  we  should  deter- 
mine its  frecjuency,  its  force,  its  fulness,  and  its  regularity. 
Position  and  action  alter  the  pulse-rate ;  for  instance,  it  is 
generally  faster  in  standing  than  in  sitting,  and  faster  in  sit- 
ting than  in  lying  down ;  it  is  slower  in  sleep,  and  faster 
toward  death  ;  it  is  slower  in  old  age  than  in  middle  life, 
slower  in  men  than  in  women,  faster  in  children  than  in 
adults,  and  faster  during  excitement  or  exercise. 

To  take  the  pulse,  two  or  three  fingers  should  be  placed  on 
the  radial  artery  at  the  wrist  or  on  the  temporal  artery  just  in 
front  of  the  ear,  counting  the  pulsations  preferably  for  a  full 
minute,  or  for  at  least  a  half  minute,  multiplying  the  result 
by  two.  The  thumb  should  not  be  placed  on  the  artery, 
because  this  method  is  awkward,  and  also  because  the  pulsa- 
tions of  the  artery  in  the  thumb  are  frequently  so  readily  per- 
ceptible as  unconsciously  to  lead  one  to  determine  his  own 
pulse-rate  rather  than  that  of  the  patient. 

The  pulse-rate  in  the  infant  at  birth  is  from  130  to  150  a  minute. 

"  '•  at     I  year  is  from    .    .-    ,    .    .  no  to  130  " 

"  '•  "     2  years       "        goto  I15  " 

"  "  "     3       "          "        80  to  no  " 

"  "  «     7       "         "        72  to    90  " 

"  "  '•  12       "         "        70  to     76  " 

"  "  ill  early  aihilt  life  is  from   .    .  70  to    75  " 

"  "  "  late        "      "         "         .    .  65  to    70  " 

26  401 


402  APPENDIX. 

In  very  old  age  the  pulse-rate  may  increase  slightly ;  and 
there  are  instances  in  which  the  normal  adult  pulse-rate  is 
rather  high,  while  in  others  it  may  be  persistently  as  low  as 
from  45  to  60. 

Body-temperature. — The  normal  temperature  of  the 
human  body  in  adults  is  98.6°  F.,  with  slight  variations  for 
different  constitutions,  the  time  of  day,  age,  mental  state, 
relation  to  meals,  etc.  It  is  often  slightly  higher  in  children, 
and  subnormal  in  advanced  age.  The  body-temperature 
gradually  rises  during  the  day,  and  is  supposed  to  reach  its 
maximum  between  5  p.  m.  and  8  p.  M.,  and  its  minimum  be-, 
tween  midnight  and  4  a.  m.  It  is  commonly  slightly  elevated 
after  a  full  meal,  exercise,  or  strong  emotions,  especially  in 
children  or  hysterical  adults.  Profuse  perspiration  tends  tem- 
porarily to  lower  the  body-temperature.  Body-temperature 
persistently  below  95°  F.  or  above  108°  F.  is  likely  to  be 
followed  by  death.  There  is  a  definite  relation  between  the 
pulse-rate  and  the  temperature,  the  pulse  commonly  increas- 
ing from  eight  to  ten  beats  with  each  additional  degree  of 
temperature.  A  sudden  and  marked  rise  or  fall  of  tempera- 
ture should  give  warning  of  the  necessity  of  immediately 
summoning  a  physician,  as  it  is  usually  indicative  of  serious 
illness.  However,  sudden  changes  of  temperature  without 
great  harm  are  frequently  noticed  in  children  and  in  hys- 
terical persons. 

Taking"  the  Body -temperature. — The  temperature  of  the 
body  is  taken  with  a  clinical  thermometer  in  the  mouth,  the 
axilla,  the  groin,  the  vagina,  or  the  rectum.  The  tempera- 
ture of  the  axilla  is  about  half  a  degree  lower  than  that  of 
the  mouth.  The  temperature  of  the  rectum  and  of  the 
vagina  is  about  half  a  degree  higher  than  that  of  the  mouth, 
because  these  cavities  are  constantly  closed. 

For  convenience,  the  temperature  is  generally  taken  in  the 
mouth.  The  thermometer  is  washed  in  cold  water  and  wiped 
dry,  the  mercury  is  shaken  down  to  95°  F.,  and  the  bulb  of 
the  thermometer  is  placed  under  the  tongue  and  the  lips  kept 
closed  for  five  minutes.  The  patient  must  be  told  not  to 
open  the  lips  while  the  temperature  is  being  taken,  or  cold 
air  will  enter  the  mouth  and  the  instrument  will  register  a 
temperature  lower  than  it  should.  Hot  or  cold  drinks  given 
immediately  before  taking  a  temperature  in  the  mouth  will 
make  the  recorded  temperature  correspondingly  higher  or 
lower.      After  each  application   the  thermometer  should  be 


n.iTiis.  403 

carefully  washed  with  soap  and  water  and  alcohol  and  steril- 
ized with  some  harmless  disinfectant. 

Respiration. — I'he  normal  number  of  respirations  in  an 
adult  is  16  to  18  a  minute — one  to  four  beats  of  the  heart. 
In  children  of  both  sexes  and  in  man  the  breathing  is  chiefly 
abdominal  and  in  women  it  is  chiefly  ihoracic.  When  taking 
the  respirations,  one  should  notice  if  they  are  regular  or 
irregular,  fre([uent,  (piiet,  deep,  shallow,  thoracic,  or  abdomi- 
nal. The  respirations  can  be  counted  by  watching  the  rise 
and  fall  of  the  chest  after  having  taken  the  pulse,  the  fingers 
being  still  on  the  wrist.  The  most  accurate  way  is  to  lay  the 
hand  lightly  on   the  chest,   but  there   is  the  danger  of  the 


Fig.  99. — Clinical  thermometer. 

patient  breathing  slower  or  faster  when  he  knows  the  respi- 
rations are  being  counted.  It  is  always  best  to  count  the 
respirations  when  the  patient  is  asleep,  as  they  are  then 
slower,  but  natural.  Respirations  are  increased  by  excite- 
ment and  exertion.  The  respirations  in  infants  are  from  30 
to  35  ;  at  the  fifth  year,  from  20  to  25  ;  after  the  eighth  year 
they  are  the  same  as  those  of  an  adult. 

BATHS. 

The  temperature  of  baths  varies,  and  the  water  must  be 
tested  with  a  bath-thermometer  (Fig.  100).  A  hot  bath  varies 
from  98°  to  110°  F.  ;  a  warm  bath  varies  from  85°  to  98° 
F.  ;  a  tepid  bath  varies  from  70°  to  85°  F. 

A  bath  must  never  be  given  sooner  than  two  hours  after 
eating,  for  the  reason  that  after  eating,  the  digestive  organs, 
as  a  rule,  are  congested,  owing  to  the  increased  activity  with 
which  they  are  obliged  to  do  their  work  in  the  process  of 
digestion. 

Hot-baths. — Hot  baths  and  vapor-baths  are  gi\-en  to  pro- 
duce perspiration.  If  a  tub-bath  is  ordered,  the  tub  may 
partly  be  filled  with  warm  water,  and  then  the  temperature 
gradually  increased  by  adding  very  hot  water.  At  the  end 
of  fifteen  minutes  the  bather  is  wrapped  in  blankets,  which 
are  tucked  in  very  securely  about  the  neck  and  body,  so  that 


404 


APPENDIX. 


no  air  can  enter.  Cold  cloths  may  be  applied  to  the  head, 
and  water  is  given  to  drink,  because  when  there  is  a  large 
quantity  of  water  in  the  body,  the  perspiration  becomes  much 
more  profuse,  and  consequently  the  impurities  thrown  off  are 
larger  in  amount.  After  the  bath  is  completed,  the  blankets 
are  removed  and  the  patient  may  be  sponged  with  warm 
water  or  with  alcohol  and  water. 

Hot  Foot-baths. — The  temperature  of  the  water  should  be 
kept  even  by  adding  hot  water.  The  bed-clothes 
at  the  foot  of  the  bed  are  loosened,  a  newspaper 
or  a  rubber  cloth  is  spread  across  to  prevent  the 
bed  from  getting  wet,  the  bather's  knees  are 
drawn  up,  the  feet  are  placed  in  the  tub,  and . 
the  clothing  is  drawn  about  the  limbs  to  pre- 
vent chilling.  When  taken  out,  the  feet  are  to 
be  wiped  dry,  care  being  taken  that  they  are 
comfortably  warm  either  by  wrapping  them  in  a 
blanket  or  by  applying  heaters. 

Hot-vapor  Bath. — A  rubber  cloth  or  an  oil- 
cloth and  blanket  are  put  on  the  bed  (the  bather 
being  turned  on  one  side,  as  is  done  in  changing 
the  bed)  ;  the  clothing  is  removed,  and  the  bather 
is  then  wrapped  snugly  in  the  blanket,  the  upper 
clothing  being  supported  by  means  of  a  cradle. 
The  clothing  should  be  well  tucked  in  about  the 
neck  and  the  sides  of  the  bed,  under  the  mattress, 
to  prevent  the  escape  of  air,  and  another  oilcloth 
put  over  all  will  make  the  covering  much  more 
air-tight.  Under  the  clothing,  at  the  foot  of  the 
bed,  is  inserted  the  spout  of  a  kettle  of  boiUng 
water,  which  can  stand  over  a  gas-  or  an  oil-stove 
or  a  spirit-lamp  placed  on  a  chair  or  a  table,  the 
whole  being  covered  with  a  blanket  to  direct  the 
steam  under  the  blankets  (Fig.  loi).  If  the  bed 
has  a  high  foot-board,  the  steam  can  be  directed  from  one 
side  of  the  foot  of  the  bed.  The  attendant  should  guard 
against  fire.  This  bath  should  be  given  only  under  the  direc- 
tion of  a  physician,  who  will  give  orders  as  to  the  length  of 
time  the  bather  is  to  remain  in  the  bath.  A  thermometer  is 
to  be  placed  in  the  bed,  and  the  steam  continued  until  the 
thermometer  registers  120°  F.  or  above,  when  the  steam  is 
stopped  and  the  bather  is  treated  as  after  the  hot  bath.  As 
the  water  in  the  kettle  boils  down  it  must  be  replaced  by 


Fig.  100. — Bath 
thermometer. 


/U  TlIS. 


405 


/'oi/i/ii:;  water,  not  l)y  liot  or  cold  water,  or  the  steam  will  stop 
until  the  water  boils  again.  C'areful  watch  must  Ijc  kept  over 
the  bather's  pulse,  which  can  be  taken  at  the  temples. 

In  the  ab.sence  of  an  oil-stove  or  a  spirit-lamp,  very  hot 
bricks,  smoothing-irons,  or  plates  may  be  wrapped  in  wet 
flannel  or  cloths;  the  hot  bricks  in  contact  with  the  wet 
cloths  will  make  steam.  'I'he  cloths  must  be  placed  about  the 
bather  on  plates  or  in  dishes  to  prevent  wetting  the  bed,  and 
care  be  taken  not  to  burn  the  bather.  The  bather  may  also 
be  seated  on  a  cane-bottom  chair,  the  clothing  being  removed, 
and  surrounded  with  blankets  or  comfortables,  which  must  be 


J  /f '/  2^7^''"''vm''>'"  Mcnm-'  ''"'y 


Fig.  ioi. — Simple  arrangement  for  giving  a  hot- vapor  bath. 


fastened  from  the  neck  down  (Fig.  102).  A  kettle  of  boiling 
water  over  a  spirit-lamp  or  an  oil-stove,  or  a  pan  or  pail  of 
boiling  water,  is  placed  under  the  chair.  The  feet  may  be 
put  into  a  pail  of  hot  water  to  increase  the  effect,  because  the 
blood-vessels  of  the  surface  of  the  body  are  dilated,  and  re- 
main so  while  the  heat  or  vapor  is  continued  ;  in  this  way  the 
activity  of  the  skin  is  increased,  the  pores  of  the  skin  are 
opened,  and  perspiration  is  produced.  The  attendant  should 
be  sure  that  the  blankets  or  coverings  are  fastened  closely 
around  the  neck  and  about  the  chair  to  prevent  the  steam 
escaping.  Cold  is  applied  to  the  head,  and  water  is  given  to 
drink,  for  the  same  reason  as  that  given  in  describing  the  hot 
baths,  and  the  after-treatment  is  the  same. 

Hot-air  Bath. — The  eeneral  details  of  giving  a  hot-air  bath 


4o6 


APPENDIX. 


are  the  same  as  those  for  giving  a  hot-vapor  bath,  with  the 
exception  of  the  use  of  water  to  generate  steam.  Tiie  hot 
air  is  generated  by  means  of  an  alcohol-lamp  or  an  oil-lamp, 
and  it  is  conveyed  to  the  bed  and  beneath  the  clothes  by 
means  of  an  elbow  of  stove-pipe. 

Acid  Steam-bath. — An  acid  steam-bath,  which  is  a  valu- 
able application  in  rheumatism,  is  given  by  preparing  the  patient 
in  the  usual  manner,  and  placing  about  her  very  hot  bricks 
wrapped  in  flannel  which  has  been  steeped  in  vinegar.  The 
bath  is  continued  for  fifteen  minutes,  after  which  the  body  is 


Fig.  I02. — Arrangement  of 
blankets  in  giving  a  hot-air  bath 
to  patient  in  sitting  position. 
(Thornton.) 


Fig.    103. — Application    of   the 
sheet-bath  (drip-sheet). 


wiped  over  with  a  towel  wrung  out  of  cold  water,  then  thor- 
oughly dried. 

The  sheet-bath,  or  drip-sheet,  which  is  frequently  applied 
in  nervous  diseases,  is  generally  given  in  the  following  way  : 
The  bather,  with  clothing  removed,  stands  in  a  tub  which 
contains  enough  warm  water  to  cover  the  feet  to  the  ankles  to 
prevent  chilling  (Fig.  103).  A  sheet  wrung  out  of  tepid  water 
is  thrown  over  the  patient  from  behind,  and  covers  the  head 
and  entire  body.  The  bather  is  then  gently  rubbed  (over  the 
sheet)   with  both   hands   to   produce  friction   and   bring  the 


/>'.  /  yy/.s".  407 

blood  to  the  surface.  As  the  sheet  becomes  warm  it  can  be 
rewet  by  pouring  water  on  it  from  a  cup  or  a  l)Ovvl.  The 
physician  will  always  give  directions  as  to  the  length  of  time 
the  i)atient  should  be  in  the  sheet.  After  being  dried,  some 
physicians  like  their  patient  to  be  put  to  bed  for  a  certain 
length  of  time,  while  others  will  leave  orders  for  the  patient 
to  dress  and  go  out  for  a  short  walk  or  to  sit  by  an  ojjcn 
window. 

The  cold  douche,  or  affusion,  is  given  by  wrapjting  the 
bather  in  a  sheet,  placing  him  in  the  bath-tub,  and  pouring 
pailfuls  of  water  over  the  body.  The  first  pailful  should  be 
tei)id,  and  be  poured  rather  slowly,  to  prevent  shock.  Kx- 
haustion  must  be  watched  for,  and  after  the  affusion  the 
patient  should  be  put  to  bed  and  wrapped  in  blankets.  An- 
other way,  one  often  employed  in  nervous  diseases,  is  to  stand 
the  bather  in  the  bath-tub,  and  direct  the  water  to  the  sjnne 
or  to  the  part  to  be  treated,  by  a  piece  of  hose-pipe  attached 
to  the  faucet. 

The  cold  pack  is  ordered  for  reducing  the  temperature  in 
many  acute  diseases.  A  rubber,  an  oilcloth,  or  a  newspaper 
is  first  put  on  the  bed,  and  over  this  one  or  two  blankets ; 
then  a  sheet  or  a  table-cloth  which  has  been  dipped  in  cold 
water  and  wrung  out  is  placed  on  the  blankets.  The  patient 
is  laid  upon  the  sheet  (the  clothing  having  first  been  re- 
moved), and  every  surface  of  the  body  is  covered  bv  pressing 
the  folds  of  the  sheet  down  between  the  arms,  body,  and 
lower  extremities.  The  sheet  is  tucked  well  in  at  the  neck 
and  feet ;  the  blankets  are  then  folded  over  and  tucked 
evenly  under  the  patient  on  both  sides.  The  feet  are  lifted 
up,  and  the  corner  ends  of  the  sheets  and  blankets  are 
tucked  under  them  (Figs.  104  and  105).  A  wet  towel  or  com- 
press is  applied  to  the  head.  The  patient  should  be  kept  in 
the  pack  ten  or  fifteen  minutes.  Besides  lowering  the  tem- 
perature, the  cold  pack  will  often  relieve  nervousness  and 
induce  sound  sleep. 

The  hot  pack  is  given  in  the  same  wa}'  as  the  cold  pack, 
with  the  exception  that  the  blanket,  the  sheets,  or  table-cloth 
is  wrung  out  of  boiling  water  by  placing  the  blanket  in  a 
sheet  and  pouring  the  boiling  water  over  them  ;  two  persons, 
each  taking  an  end  of  the  sheet,  wring  in  opposite  directions. 
More  coverings  are  placed  over  the  patient  than  in  the  cold 
pack.  Should  the  attendant  not  have  anything  with  which 
to   prevent    the    mattress  from   getting  wet,  a  table  may  be 


40-8 


A  PF END  IX. 


arranged  with  blanket  and  sheets  ;  in  the  absence  of  a  table, 
the  floor  near  the  bed  may  be  prepared.  Towels,  table- 
cloths, and  old  linen  may  be  used  where  there  are  but  iQ^^f 


Fig.  104. — Application  of  the  cold  pack    (pressing  the  sheet  between  the 
patient's  arm  and  body). 

sheets.     After  the  pack  the  sheets  and  blankets  are  removed, 
the  patient  is  wiped  dry  with  soft  towels,  the  clothing  is  put 


Fig.  105. — Application  of  the  cold  pack  (patient  completely  covered,  with 
wet  towel  on  the  head). 

on.  heat  is  applied  if  necessary,  and  the  pulse  and  tempera- 
ture are  taken.  Partial  packs  are  compresses  applied  to  dif- 
ferent  parts   of  the  body,  and  covered  with  a  flannel  or  a 


MASSAGE.  409 

cotton   bandage   to  prevent  the  patient's  clothing  becoming 
damp. 

MASSAGE. 

The  value  of  massage  lies  in  the  stimulation  of  the 
peripheral  nervous  system,  the  increased  tonicity  of  the  circu- 
latory system,  particularly  the  vasomotor  apparatus,  the  aiding 
of  metabolism,  and  the  exercise  and  development  of  muscles, 
without  exhaustion  of  the  central  nervous  system,  besides 
these  advantages,  the  soothing  influence  of  the  rubbing  itself 
is  of  great  benefit  to  persons  who  are  nervously  exhausted. 
The  special  uses  of  massage  in  the  treatment  of  disease  are 
not  within  the  scope  of  this  work. 

General  Rules. — The  person  administering  massage  should 
have  soft,  clean,  warm,  and  dry  hands.  A  general  rub  should 
be  given  about  bed-time,  and  should  last  from  one-half  to  one 
hour.  Massage  should  not  be  administered  for  an  hour  after 
a  meal.  Contraindications  are  fever,  enlarged  veins,  tumors, 
pregnancy,  and  when,  as  rarely  happens,  it  irritates  rather 
than  soothes.  Massage  in  the  day-time  should  be  followed 
by  an  hour's  rest. 

Several  special  methods  of  movements  have  been  de- 
vised, but,  as  a  rule,  the  claims  for  them  are  delusionary. 
The  simple  common -sense  method  of  rubbing  outlin.ed  by 
Dr.  F.  S.  Pearce,^  and  given  in  the  following  paragraphs, 
contains  the  most  important  movements  found  in  the  several 
"special  schools." 

The  movements  of  massage  are  : 

1.  Effleuragc,  the  gentle  surface  stroking  of  the  part,  which 
quietly  starts  the  circulation  before  the  more  vigorous  rubbing 
begins. 

2.  Friction,  which  consists  in  a  firmer  and  deeper  pressure- 
rub  than  the  preceding  movement. 

3.  Petrissage,  which  is  a  very  deep  kneading  of  the  part,  and 
completes  what  has  been  begun  by  i  and  2.  It  is  essential  in 
petrissage  to  hold  firmly  to  the  skin,  and  to  make  this  rub 
the  subcutaneous  tissues,  while  the.  last  in  turn  presses  the 
muscles,  and  so  on  until  the  soft  parts  are  so  manipulated, 
squeezed,  and  pressed  against  the  bones  of  the  patient  that  a 
veritable  pushing-on  of  all  the  liquids  (blood  and  lymph) 
takes  place  ;  also,  indeed,  of  some  of  the  semisolids,  which 
become  disintegratedr-and  their  ultimate  particles  are  swept 

'  International  Medical  Magazine,  February,  1 902. 


4iO  APPENDIX. 

on  in  the  hurried  circulation  to  be  oxidized  or  converted 
into  energy,  or  to  be  excreted,  instead  of  remaining  in  the 
body  as  sources  of  irritation  in  the  form  of  what  we  call 
leukomains. 

4.  Tapotement,  or  tapping  in  a  rapid,  vibratory  manner 
with  the  balls  of  the  fingers  of  one  or  both  hands  held 
gently  closed,  similar  to  the  position  of  holding  a  pen.  This 
movement  is  not  so  very  essential,  but  is  sometimes  used 
as  a  final  stimulator  of  the  circulation  when  it  is  extremely 
sluggish. 

The  foregoing  manipulations  are  followed  with  efifleurage, 
shading  off  into  very  gentle  strokings  which  are  soothing  to 
the  part  and  to  the  patient  generally,  while  they  also  equalize 
the  blood  circulating  in  the  superficial  tissues. 

Method. — The  subject  is  required  thoroughly  to  relax  all 
his  muscles,  and  is  then  placed  on  his  right  side.  The  man- 
ipulations are  begun  on  the  left  foot,  toes,  ankle,  thigh,  hip, 
and  buttock,  in  turn  ;  using  all  the  movements  described  over 
each  part,  varying  the  time  and  duration  of  each  in  propor- 
tion to  the  size,  rigidity,  and  amount  of  muscle  or  other  soft 
tissues  present.  The  patient  is  then  asked  to  turn  toward 
the  opposite  side,  and  the  right  foot,  leg,  thigh,  and  buttock 
are  rubbed  in  the  same  thorough  fashion. 

Next  the  left  fingers,  forearm,  arm,  and  shoulder  are  first 
given  the  long,  sweeping  efifleurage,  followed  again  by  the 
rest  of  detailed  movements  described ;  but  the  eye  has  to 
follow  quickly  to  appreciate  the  rapid  changes,  so  much  a  part 
of  the  manipulator  does  the  patient  become.  Four  or  five 
minutes  will  suifice,  and  the  right  arm  is  now  taken  up.  After 
this  the  patient  is  requested  to  lie  on  his  abdomen,  and  a 
pillow  is  placed  under  him  for  better  resistance.  The  long 
series  of  strokings  down  the  vertebral:  gutters  are  made  alter- 
nately with  the  fingers  of  each  hand  spread  on  either  side  of 
the  spinous  processes.  Then  comes  a  series  of  circular  fric- 
tions down  each  recti  group  with  one  hand  ;  then  a  spreading 
movement  from  the  spines  outward  with  the  balls  of  both 
thumbs;  next  a  firmer  petrissage  wnth  both  hands;  followed 
by  that  motion  with  the  palms  of  both  hands  alternately  run 
down  either  side  of  the  spinal  column,  giving  a  delightful 
sensation  ;  while  the  final  effleurage  finishes  and  the  patient 
is  requested  to  turn  on  the  broad  of  his  back,  the  pillow  being 
removed. 

The  chest  movements  consist  principally  of  two  :  a  firm 


ACCIDENTS  ANJy   EMERGF.NCTES.  411 

stroking,  following  the  ribs  from  the  sternum  out  and  down  ; 
and  of  firmer  petrissage,  in  which  the  balls  of  both  thumbs 
play  an  imi)ortant  role  and  can  be  so  dexterously  done  as  to 
be  not  at  all  i)ainful,  which  occasionally  happens  with  the  be- 
ginner. 

The  abdomen  rubljing  is  very  important  and  difficult  of 
performance :  The  thighs  are  flexed  on  the  abdomen  and  legs 
on  the  thighs  in  order  to  relax  the  anterior  abdominal  walls. 
The  effleurage  is  simple,  but  it  requires  tact  to  knead  thor- 
oughly without  tickling.  'J'his  should  be  begun  over  the  small 
intestine,  working  with  both  hands  in  a  "  spanning  "-like 
manner.  Then  start  at  the  head  of  the  colon,  and  work  along 
the  ascending,  transverse,  and  descending  i)ortions,  one  hand 
following  the  other  in  rotary  motions.  Again  effleurage 
follows,  and  if  there  is  constipation,  that  series  of  rapid 
vibrations  described  will  aid  much  toward  the  cure.  As  a 
rule,  the  face,  head,  and  neck  are  not  rubbed  in  ordinary 
work.  When  specially  requested,  this  is  done  by  a  series  of 
strokings  and  kneading  movements  in  the  direction  of  the 
venous  circulation.  In  all  movements  the  greater  pressure 
should  be  from  the  periphery  toward  the  heart — /.  e.,  cetitrip- 
etal  in  character. 

ACCIDENTS  AND  EMERGENCIES. 

A  cut  or  incised  wound,  is  made  by  some  sharp  cutting 
instrument.  If  deep  or  extensive,  or  if  bleeding  very  freely, 
it  should  have  surgical  attention  at  once.  A  small  cut  should  be 
washed  gently  but  thoroughly  with  absorbent  cotton  and  cold 
or  very  hot  water  (which  will  both  cleanse  it  and  help  to 
arrest  the  bleeding)  and  then  with  an  antiseptic  solution.  A 
compress  made  of  clean  folded  linen  or  muslin  wet  with  the 
solution  should  now  be  placed  over  the  wound  and  bound  on, 
not  too  tighdy,  with  a  roller  bandage.  If  the  bleeding  will 
not  stop,  the  bandage  must  be  applied  with  moderate  firmness, 
or  pressure  be  made  with  a  finger.  If  the  blood  spurts  out  of 
the  wound  in  jets,  an  artery  has  been  injured.  Bleeding  from 
this  or  from  any  other  wound  can  always  be  stopped  until  a 
physician  arrives  by  making  pressure  with  the  fingers  directly 
into  the  wound.  The  pressure  must  be  constant,  and  not  re- 
laxed every  few  minutes  to  see  if  the  flow  has  ceased.  The 
use,  by  others  than  physicians,  of  what  is  called  a  tourniquet 
— such,  for  instance,  as  a  twisted  handkerchief  (.Fig.  106)  or 


412  APPENDIX. 

a  cord  tied  tightly  around  the  arm  or  the  leg — is  not  only 
very  painful,  but  is  dangerous  also,  since  it  may  cause  serious 
sloughing  and  death  of  the  tissues. 

When  a  finger  is  cut  off,  it  should  be  immediately  washed 
carefully,  and  fastened  firmly  in  place  again  with  adhesive 
plaster,  and  a  ph}^sician  sent  for.  It  sometimes  happens  that 
the  severed  portion  will  grow  fast. 

A  tear,  or  lacerated  wound,  is  produced  by  some  dull 
body,  such  as  a  nail  or  a  brick.  It  has  ragged  edges  and  does 
not  often  bleed  much.  Unless  very  small,  a  physician  should 
treat  it,  since  wounds  of  this  sort  are  more  likely  to  leave 
scars.  A  small  tear  must  be  cleansed  carefully  with  luke- 
warm water,  followed  by  an  antiseptic  solution,  as  it  is  very 
apt  to  have  dirt  in  it.  The  torn  edges  should  be  brought 
together  as  well  as  possible,  and  the  wound  covered  with  a 
compress  wet  with  the  antiseptic  fluid  and  bandaged  up  loosely. 


Figs.  io6,  107. — Impromptu  tourniquets  for  compressing  an  artery  with 
handkerchief  and  a  stick. 


handkerchief  and  a  stick. 

Punctured  wounds  are  those  made  by  sharp-pointed  ob- 
jects, such  as  pins,  needles,  fish-hooks,  tacks,  splinters,  and 
the  like.  They  are  often  painful  and  attended  by  a  good  deal 
of  swelling.  The  object  must  be  removed  and  the  injured  part 
squeezed  gently  in  warm  water  in  order  to  favor  the  flow  of 
blood,  which  will  help  to  wash  away  the  impurities  which  may 
have  entered.  If  there  is  a  tendency  to  swelling,  a  warm 
antiseptic  poultice  may  be  applied. 

In  case  a  needle  has  entered  and  remained  in  the  flesh,  great 
care  should  be  taken  not  to  break  it  in  attempting  to  remove 
it,  and  it  should  be  closely  examined  after  removal  to  see  that 
it  is  quite  intact.  If  it  has  been  broken,  a  surgeon  must  be 
called  in  and  the  fragment  saved  to  show  him. 

Fish-hooks  which   have   entered  beyond   the  barb  must 


SVVA'G'.S  AA7)    BITES.  4I3 

be  cut  out  or  he  pushed  through  tht;  skin  from  inside,  cither, 
but  never  torn  out. 

If  any  portion  of  a  splinter  is  ])rolruding,  it  may  l)e  seized 
with  small  pliers  or  tweezers  and  pulled  out,  care  being  taken 
to  avoid  any  side  motion,  lest  the  wood  break  off.  If  it  can- 
not be  removed  in  this  way,  it  may,  perhaps,  be  picked  out 
with  a  needle.  vShould  a  splinter  too  short  to  grasp  have 
lodged  beneath  the  finger-nail,  the  nail  should  be  carefully 
scraped  very  thin  over  it  and  then  be  split  open  with  the 
point  of  a  sharp  knife,  just  enough  to  allow  of  the  top  of  the 
piece  of  wood  to  be  seized.  This  should  be  done  under  anti- 
septic precautions  and,  if  possible,  always  by  a  physician. 

Insect-stings  belong- to  the  class  called  poisoned  wounds. 
They  are  seldom  dangerous,  although  for  a  time  quite  painful. 
Careful  examination  may  show  the  sting  of  the  insect  still  in 
the  wound.  It  should  be  pulled  out  with  tweezers,  and  water 
of  ammonia  or  spirits  of  camphor  applied,  h  cold-water 
dressing  may  then  be  employed  to  prevent  swelling.  The 
application  of  mud  is  useful. 

Mosquito-bites  are  often  a  source  of  great  annoyance  and 
disfigurement.  The  annoying  itching  may  be  allayed  by 
touching  the  bites  with  carbolized  oil,  ammonia,  or  spirits  of 
camphor,  or  with  a  cooling  evaporating  lotion.  Dampened 
salt  rubbed  on  the  spot  is  sometimes  useful. 

Dog-bites  or  the  bites  of  other  animals,  as  the  cat  or  rat, 
are  sometimes  productive  of  severe  inflammation,  and  even 
of  decided  illness.  It  is  rare,  however,  that  hydrophobia 
follows.  The  dog  which  has  bitten  any  one  should  on  no 
account  be  killed  until  it  has  been  kept  long  enough  to  de- 
termine whether  or  not  it  was  mad.  To  find  that  the  animal 
was  not  rabid  will  be  a  great  relief  to  all  concerned.  Wounds 
produced  by  the  bite  of  an  animal  should  be  pressed  out 
thoroughly  under  warm  water  or  be  w^ell  sucked.  They  may 
then  be  covered  with  a  cold  wet  dressing.  The  patient  should 
seek  medical  aid  immediately  ;  and  if  the  bite  is  that  of  a 
dog  undoubtedlv  mad  the  part  must  be  cut  out  quickly,  or  be 
cauterized  deeply  with  a  red-hot  iron  or  wnth  strong  carbolic 
or  some  mineral  acid,  such  as  sulphuric  or  nitric. 

Snake-bites  constitute  a  variety  of  poisoned  wounds  fortu- 
nately not  often  met  with  in  this  part  of  the  world.  If  the 
snake  was  a  venomous  one,  a  cord  should  at  once  be  tied 
around  the  limb  above  the  wound  to  stop  the  progress  of  the 
blood  and  to  keep  the  poison  out  of  the  general  circulation. 


414  APPENDIX. 

The  wound  should  be  squeezed  out  under  water,  or  may  be 
sucked  thoroughly,  provided  the  lips  of  the  person  who  does 
this  are  quite  free  from  cracks.  Medical  assistance  should  be 
summoned  at  once,  and  the  wound  ought  to  be  cut  out  or 
cauterized,  as  in  the  case  of  dog-bites.  Stimulants  in  large 
quantity  have  been  recommended,  and  are  perhaps  of  service. 
A  solution  of  permanganate  of  potash  of  the  strength  of  20 
grains  to  the  ounce  should  be  used  to  wash  the  wound. 

Ivy  Poisoning. — The  intolerable  itching  may  be  relieved 
by  plain  water,  baking-soda  and  water,  lime-water,  lead-water 
and  laudanum,  grindelia  robusta,  etc. 

Bruises  or  contusions  generally  do  little  damage  other 
than  temporarily  to  disfigure.  A  painful  swelling  develops, 
rapidly  increases  in  size,  and  turns  deep  purple  as  the  re- 
sult of  the  escape  of  blood  under  the  skin.  This  color 
gradually  passes  through  different  shades  of  green  and  yellow 
until  the  blood  has  been  absorbed.  To  prevent  the  swelling 
and  discoloration  to  any  degree,  the  treatment  must  be  begun 
at  once.  Firm  pressure  may  be  kept  up,  or  compresses  wet 
with  ice-water,  very  hot  water,  or  alcohol  and  water  con- 
tinuously applied.  The  colorless  fluid  extract  of  witch-hazel 
put  on  at  once  on  a  compress  is  excellent  treatment.  If  dis- 
coloration has  occurred,  its  disappearance  may  be  hastened 
by  rubbing  the  bruise  with  some  bland  ointment  like  lanolin. 

Sprains. — A  twisting  or  straining  of  a  joint,  or  a  sprain, 
produces  great  pain  on  motion,  rapid  swelling,  and  often  a 
discoloration  of  the  skin  like  that  of  a  bruise.  Although  in 
many  instances  sprains  are  slight  and  are  quite  well  in  a  few 
days,  in  some  severe  ones  recovery  is  very  slow  and  the  bad 
effects  are  more  lasting  than  in  the  case  of  broken  bones. 
Recent  x-ray  photographs  of  obstinate  sprains  have  demon- 
strated coincident  fracture  of  a  neighboring  bone.  Every 
sprain  except  the  very  mildest  should  have  a  physician's  at- 
tention as  early  as  possible.  If  this  cannot  be  procured,  the 
joint  should  be  soaked  for  from  twenty  to  thirty  minutes  in 
very  hot  water  and  then  be  put  at  absolute  rest.  If  it  is  the 
ankle  or  the  knee  which  is  injured,  the  patient  must  be  kept 
in  bed,  with  the  part  elevated  and  covered  with  a  dressing  of 
cold  water  or  of  witch-hazel.  In  the  case  of  the  arm,  the 
joint  must  be  kept  quiet  on  a  pillow  or  supported  on  a  splint 
or  in  a  sling  with  the  dressing  applied.  After  the  acute  pain 
and  all  signs  of  inflammation  have  disappeared, — which  is 
often  a  matter  of  days  or  even  of  weeks, — the  joint  may  be 


FRACTURES  AND   I)/SLOCA770NS.  415 

rubbed  daily  with  soap  linimcnl  or  chloroform  liniment  and 
very  carefully  and  slightly  moved.  Under  the  special  sup- 
porting dressings  which  surgeons  employ,  the  confi'nement  to 
bed  after  sprains  of  the  lower  extremities  is  greatly  curtailed. 

Fractures. — A  single  break  in  a  bone  without  injury  to 
the  flesh  is  called  a  simple  fracture.  If  the  flesh  is  injured, 
the  fracture  is  called  coinpotiiid,  and  is  of  a  much  more  serious 
nature.  A  orcc//-s/ick  fracture  is  one  in  which  the  bone  is 
bent  and  only  partially  broken.  It  occurs  chiefly  in  children. 
The  management  of  a  fracture  before  the  arrival  of  the  surgeon 
consists  in  securing  perfect  rest.  If  a  leg  be  broken,  the 
patient  should  be  laid  on  a  stretcher,  a  door,  or  a  shutter,  and 
a  splint  may  be  improvised  with  an  umbrella,  a  walking-stick, 
a  thin  board,  books,  newspapers,  or  a  coat  rolled  up  and  tied 
to  the  side  of  the  leg  with  handkerchiefs  above  and  below 
the  break.  If  none  of  these  articles  is  at  hand,  the  legs  may 
be  tied  together.  Clothes  should  not  be  torn,  but  opened  at 
the  seams.  To  remove  boots,  one  hand  should  be  placed  at 
the  ankle  to  steady  the  limb.  If  the  foot  is  injured  or  there 
is  much  pain,  the  seam  of  the  boot  may  be  cut.  Great  care 
should  be  taken  to  prevent  further  injury  to  the  limb  by  rough 
handling.  If  there  is  much  shock,  heat  should  be  applied 
and  stimulants  administered. 

Dislocations  consist  in  the  displacement  of  the  bone  or 
bones  of  a  joint  by  some  external  violence,  such  as  a  fall  or  a 
blow.  The  patient  should  be  put  to  bed  on  his  back,  the 
part  bandaged,  and  ice  applied  to  prevent  inflammation,  and 
a  surgeon  summoned. 

Dislocation  of  the  lower  jaw,  which  is  sometimes  caused 
by  yawning,  can  generally  be  overcome  by  wrapping  the 
thumbs  in  a  handkerchief  and  placing  them  in  the  patient's 
mouth  on  the  lower  back  teeth  and  pressing  down  and  back, 
when  the  bone  will  generally  slip  into  its  place. 

Handkerchief  bandages  (Figs.  108-111I  are  very  useful 
in  emergencies.  They  consist  of  large  handkerchiefs  or  of 
pieces  of  linen  or  muslin,  each  32  inches  square.  The  tri- 
angle is  made  by  cutting  the  square  diagonally,  so  that  two 
three-cornered  pieces  are  the  result.  A  cravat  is  made  by 
folding  in  the  sharp  corner  toward  the  base  of  the  triangle 
until  a  bandage  about  3  inches  wide  is  formed. 

The  four-tailed  bandage  (  Fig.  1 12)  is  useful  for  dressings 
about  the  face  (Fig.  116),  the  scalp  (Figs.  114,  115),  and  the 
knee. 


4i6 


APPENDIX. 


A  many -tailed  bandage  (Fig.  113)  is  applied  to  a  limb 
which  requires  frequent  dressing,  and  consists  of  a  piece  of 
linen  or  muslin  the  length  of  the  limb  and  wide  enough  to  go 
one  and  one-half  times  around.  The  muslin  is  torn  from 
each  side,  in  strips  about   2  inches  wide,  to  within  about  3 


Fig.  108. — Various  forms  of  handkerchief  bandages:  a,  for  the  chest; 
b,  for  the  shoulder,  hand,  and  arms ;  c,  double  bandage  to  prevent  motion 
of  the  arm. 

inches  of  the  middle.  The  central  part  is  placed  under  the 
limb,  and  the  tails  are  drawn  to  the  front  over  the  dressing 
and  tied  ;  beginning  at  the  lowest  pair,  the  ends  are  brought 
up  and  the  next  pair  tied  over  them. 


Fig.  109.— Handker-  FIG.  no.— Three-cor-  FiG.  in.— Four-cor- 

chief  bandage  for  peri-     nered  bandage  for  arm.       nered  bandage  for  arm. 
neum  and  hip. 

Burns  and  Scalds. — A  burn  is  the  result  of  contact  with 
a  flame  or  with  dry  heat  of  some  sort,  while  a  scald  is  pro- 
duced by  a  hot  fluid.  For  convenience,  we  may  call  them 
both  burns,  for  the  injury  to  the  tissues  is  the  same  in  each, 


BURNS  AND   SCALDS. 


417 


except  that  the  damage  from  liol  li(|iii(ls  is  apt  to  be  less 
deep.  The  danger  to  life  from  a  burn  depends  more  U]jon 
its  extent  of  the  surface  than  u[)on  its  depth.  On  the  other 
hand,  the  degree  of  subse(|uent  deformity  depends  U|)on  tlie 
depth  of  the  injury.     If  half  of  the  surface  of  the   body  is 


^ 


Fig.  112. — Four- tailed  bandage. 


Fig.  113. — Many-tailed  bandage. 


involved,  the  result  is  nearly  always  fatal.  In  the  more 
superficial  burns  the  skin  is  reddened  and  perhaps  blistered, 
while  in  the  deeper  ones  it  is  yellowish-white  or  blackened. 
The  pain  is  usually  very  severe,  yet  in  the  worst  cases  the 
patient  may  suffer  very  little,  but  be  so  alarmingly  prostrated 
l3y  the  shock  that  death  follows  in  a  few  hours. 

When  the  clothes  are  on  fire  the  head  should  be  placed 


Figs.  114,  115. — Four-tailed  bandage  for 
the  head. 


Fig.  116. — Four-tailed  band- 
age for  the  jaw. 


low,  for  the  flames  naturally  tend  to  rise,  and  burns  about  the 
head  and  hands  are  the  most  disfiguring.  Burning  clothes 
should  be  wrapped  about  with  some  thick  woolen  material, 
such  as  a  piece  of  carpet,  a  rug,  table-cover,  dress-skirt,  shawl, 
or  overcoat,  beginning  always  at  the  neck.     Cotton  and  linen 


27 


41 8  APPEAWIX. 

articles  catch  fire  too  easily  themselves,  but  even  these  are 
better  than  nothing,  for  if  quickly  applied  they  may  smother 
the  flames  before  they  are  ignited.  Nothing  can  be  better  than 
a  tub  or  bucket  of  water  dashed  over  the  patient,  if  this  hap- 
pens to  be  at  hand.  Running  about  the  room  or  into  the 
open  air  only  fans  the  fire. 

The  treatment  of  burns  and  scalds  consists  in  first  at- 
tending to  the  shock  by  the  application  of  heat  to  the  body,  or, 
if  possible,  in  giving  a  hot  bath  (temperature,  ioo°  F.),  the 
administration  of  stimulants  (alcohol  or  black  coffee),  and  the 
application  of  a  mustard-plaster  over  the  heart.  The  clothing 
is  to  be  removed  gently,  being  cut  if  necessary.  If  the  burn 
is  slight  and  no  blisters  have  formed,  the  part  is  to  be  dressed 
with  a  saturated  solution  of  ordinary  baking-soda  or  dusted 
with  baking-soda,  flour,  or  starch,  and  the  air  excluded, 
because  air  is  an  irritant.  The  blisters  may  now  be  pierced 
at  the  edge  with  a  clean  needle,  which  has  been  sterilized  by 
holding  it  a  moment  in  the  flame,  and  the  burnt  parts  covered 
with  soft  linen  cloths  saturated  with  boric-acid  lotion  or  the 
boric-acid  ointment.  Lastly,  the  whole  should  be  enveloped 
in  raw  cotton,  oiled  silk,  or  paraffin  paper,  and  bandaged 
loosely  in  order  to  exclude  the  air  still  more  perfectly.  Hot 
bottles  should  be  applied  to  portions  of  the  body  which  have 
not  been  burnt  if  the  prostration  continues.  The  after-treat- 
ment must  be  managed  by  a  physician. 

Burns  with  acids  should  have  the  liquid  washed  away 
quickly  with  water,  or,  still  better,  with  a  solution  of  baking- 
soda. 

Bums  with  alkalis,  as  lye,  should  be  treated  quickly  with 
vinegar  and  water.  The  burns  may  then  be  dressed  with  oily 
applications,  such  as  olive  oil,  vaselin,  or  zinc  ointment. 

The  inhalation  of  steam  or  the  drinking  of  scalding- 
liquids  may  cause  edema,  or  dropsy  of  the  glottis.  Edema  is  a 
pouring-out  of  the  watery  part  of  the  blood  into  the  tissues,  and 
the  effusion  may  increase  with  great  rapidity.  Death  by  suffo- 
cation may  occur  within  a  very  short  time.  The  symptoms  of 
edema  are  gradual  loss  of  voice,  difficulty  in  breathing,  and 
blueness  of  the  surface  of  the  body  (c)^anosis)  from  insuffi- 
cient oxidation  of  the  blood,  gasping  respirations,  and  a  flick- 
ering pulse.  As  an  artificial  opening  into  the  trachea,  or 
windpipe,  may  be  demanded,  a  surgeon  should  be  summoned 
immediately. 

"What  to  do  in  case  of  fire"  is  the  title  of  a  very 


JIOUSKllO/.D    CONFLAGRA'J'WNS.  419 

timely  editorial  in  the  /iidcpriidcnl,  May  14,  1904,  based  ii])on 
some  recent  suggestions  to  householders  by  Fire  Chief  Coots, 
of  Indianapolis,  Jnd.  The  first  essential  is  calmness  and 
deliberation,  instead  of  the  ordinary  and  totally  unnecessary 
excitement,  terror,  and  recklessness. 

The  fire  victim  should  make  certain  that  a  fire  alarm  has 
been  turned  in.  When  an  alarm  is  sounded  in  good  faith,  the 
department  has  no  complaint  to  make  because  it  happens  that 
its  services  are  not  needed.  It  is  better  for  it  to  get  there 
too  soon  than  too  late.  The  inside  door  of  the  burning 
building  should  be  tightly  closed.  So  also  with  the  outside 
doors  and  windows.  When  this  much  has  been  accom- 
plished, it  is  best  to  wait  the  coming  of  the  firemen.  They 
ought  to  arrive  within  two  or  three  minutes  under  ordinary 
circumstances.  Some  one  should  be  ready  to  point  out 
exactly  where  the  fire  is  and  the  best  way  of  reaching  it.  In 
a  large  number  of  cases,  fires  start  in  the  rear  of  dwelling 
houses,  usually,  it  may  be  said,  from  the  kitchen  flue,  or  else 
from  the  furnace,  which  is  frequently  located  under  the  din- 
ing room.  Through  the  device  of  shutting  the  doors  of  the 
several  rooms,  both  up  and  down  stairs,  the  flame  and  smoke 
are  prevented  from  spreading  through  the  house.  In  many 
cases  the  fire  department  is  thus  able  to  confine  the  mischief 
to  the  original  room  in  which  the  fire  originated.  If  the  in- 
mates of  the  burning  house  have  given  timely  alarm,  and 
carefully  attended  to  the  foregoing,  there  is  but  little  danger 
of  a  general  spread  of  the  fire. 

It  has  happened  more  than  once  that  the  department  has 
been  seriously  handicapped  by  attempts  made  by  the  family 
to  save  household  goods  and  trinkets.  Many  times  the  fire- 
men have  been  blocked  while  on  their  way  to  the  upper 
rooms  by  furniture  that  was  being  carried  down  stairs,  or  by 
heavy  trunks  that  have  been  dragged  to  the  top  steps  and 
allowed  to  tumble  down.  If  intelligence  is  used  much  can 
be  done  to  protect  property  from  the  ravages  of  the  flames. 
There  is  loss  rather  than  gain  in  pitching  one's  effects  out  of 
doors,  where,  if  it  is  not  injured  by  the  fall,  it  is  more  than 
likely  to  be  trampled  upon  and  damaged  by  the  water  thrown 
upon  the  fire.  Paintings  and  pictures  are  among  the  things 
most  easily  ruined  by  heat  and  smoke.  If  the  circumstances 
are  favorable  and  there  is  time,  these  mav  be  removed  from 
their  hangings  on  the  walls  of  the  threatened  room.  It  is  wiser 
to  depend  on   the  salvage  corps,  which  responds  promptly 


420  APPENDIX. 

and  understands  the  saving  of  household  goods  better  than 
the  owners,  because  the  members  of  this  corps  have  the  ex- 
perience, strength,  and  means  with  which  to  work.  It  is 
surprising  to  the  onlooker  how  quickly  household  property 
can  be  gathered  into  the  middle  of  a  room  and  covered  with 
protecting  tarpaulins  against  injury  by  water  or  falling  plaster. 
Sometimes,  if  the  precautions  mentioned  are  faithfully  ob- 
served, a  fire  may  be  extinguished  through  the  use  of 
chemicals  with  only  nominal  damage. 

Frost-bite  and.  Freezing-. — The  first  effect  of  long  ex- 
posure to  cold  is  to  make  the  skin,  usually  of  the  fingers, 
toes,  nose,  or  ears,  numb,  white,  and  wrinkled.  Then,  upon 
coming  into  a  warm  place,  the  parts  become  red,  swollen, 
and  itching.  If  the  action  of  the  cold-  has  been  severe, 
blisters  form  over  the  frozen  skin,  and  finally  mortification 
may  set  in.  Generally,  under  proper  treatment,  the  frozen 
part  regains  its  sensation  and  becomes  painful  for  a  time,  the 
swelling  disappears,  and  there  is  no  further  trouble.  In  the 
case  of  those  who  have  been  nearly  "  frozen  to  death,"  the 
whole  body  is  affected  by  the  cold  and  there  is  unconscious- 
ness. In  the  treatment  of  freezing,  the  patient  should  be 
kept  in  a  cool  room  for  some  hours,  and  the  frozen  parts^ — or 
the  whole  body,  if  it  is  a  case  of  general  freezing — ^be  rubbed 
with  cold  water  or  snow  or  wrapped  in  cold  wet  cloths.  A 
bland  antiseptic  ointment  may  then  be  applied.  The  re- 
moval to  a  warm  place  should  be  made  with  the  greatest  care. 
Sometimes  a  frozen  part  may  afterward  be  subject  to  chil- 
blains. 

Sunstroke. — The  symptoms  of  sunstroke  are  a  tempera- 
ture of  from  105°  to  112°  F.,  sometimes  higher,  a  flushed 
face,  stertorous  breathing,  and  unconsciousness.  The  patient 
should  be  put  into  a  cold  bath  and  rubbed  with  ice.  If  at 
the  seaside,  he  may  be  carried  to  the  beach  and  put  in  the 
water;  the  head  may  be  kept  cold  by  bathing  it  or  by  the 
application  of  handkerchiefs  wrung  out  of  the  water.  If 
a  cold  bath  is  impossible,  the  patient  may  be  douched  with 
cold  water  from  a  hose-pipe  or  from  pails,  and  cold  cloths  be 
kept  on  the  head.  The  cold-water  treatment  must  be  con- 
tinued until  the  temperature  has  fallen,  after  which  the  patient 
should  be  put  to  bed,  and,  if  there  is  depression,  be  given 
stimulants  moderately.  Should  the  temperature  begin  to  rise, 
the  above  treatment  should  be  renewed. 

Heat-exhaustion  is  caused  by  too  long  exposure  to  a  very 


DROlVNfNG.  421 

high  temperature;  the  blood  leaves  the  bniin  and  the  surface 
of  the  body  and  goes  to  the  large  blood-vessels  of  the  abdo- 
men. 'I'he  symptoms  are  those  of  shock.  The  treatment  is 
the  same  as  that  for  shock:  hot  bath  if  possible,  or  heat  ap- 
plied to  all  parts  of  the  body  ;  stimulants  of  alcohol  or  strong 
coffee. 

For  lightning-stroke  and  electrical  injuries  the  treat- 
ment is  the  same  as  that  for  shock  and  for  burns. 

Fainting. — The  head  of  a  person  in  a  faint  should  be 
lowered  and  the  feet  raised,  the  blood  being  thus  sent  back 
to  the  brain.  Plenty  of  air,  the  clothing  loosened  about  the 
neck  and  chest,  and  a  little  cold  water  dashed  over  the  face 
are  usually  sufficient  to  restore  consciousness.  A  method 
often  practised  is  to  place  the  patient  on  a  chair,  and  to  push 
the  head  down  between  the  knees,  the  hands  hanging  down 
at  the  side.  The  patient  is  kept  in  that  position  until  the 
face  becomes  red,  being  then  able  to  rise  and  walk  about. 
This  position  restricts  the  abdomen  and  shuts  off  the  blood- 
supply  to  the  lower  extremities,  the  blood  going  to  the  brain. 
Strong  ammonia  should  not  be  held  to  the  nostrils  of  an  un- 
conscious patient,  as  it  is  very  irritating.  The  pulse  should 
be  watched,  and,  if  consciousness  does  not  soon  return,  heat 
should  be  applied  and  a  physician  be  sent  for.  Little  can  be 
done  for  loss  of  consciousness  from  heart-failure  beyond  stimu- 
lating a  flagging  pulse  until  the  arrival  of  medical  assistance. 

Dro"WTiing. — In  asphyxia  or  suffocation  from  drowning,  if 
the  person  when  taken  from  the  water  is  breathing,  he  should 
be  removed,  if  possible,  to  a  near-by  house  and  put  into  a 
hot  bath,  which  will  act  as  a  stimulant  ;  or  heat  may  be  applied 
directly  over  the  heart  and  other  vital  organs,  the  head  and 
shoulders  be  raised,  stimulants  given,  and  the  body  briskly 
rubbed.  This  can  be  done  until  the  arrival  of  a  physician. 
In  all  cases  of  suffocation  the  throat  must  be  cleared,  so  that 
fresh  air  can  reach  the  lungs. 

Artificial  respiration  is  the  imitation,  as  nearly  as  possi- 
ble, of  natural  breathing.  We  breathe  from  sixteen  to  eight- 
een times  a  minute  ;  this  number  of  chest  movements  must 
not  be  exceeded,  or  the  lungs  cannot  expand  to  fill  thoroughly 
with  air  nor  contract  to  expel  the  air. 

To  produce  artificial  respiration  in  case  of  drowning  or  of 
suffocation,  the  patient's  clothing  is  first  removed  and  the 
body  is  quickly  dried.  The  mouth,  the  throat,  and  the  nose 
should  be  cleared,  and  the  tongue  be  pulled  forward  to  facili- 


422  APPENDIX. 

tate  access  of  air  to  the  windpipe ;  a  roll,  a  pillow,  a  rolled- 
up  coat,  or  a  piece  of  wood  should  be  placed  under  the 
shoulders.     The  arms  near  the  elbows  should  now  be  grasped 


Fig.  117.— Artificial  respiration  :  first  movement,  inspiration  (Murray). 

and  be  swept  around  horizontally,  away  from  the  body,  until 
the  hands  meet  over  the  head  (Fig.  117)  ;  this  movement 
raises  the  ribs  and  expands  the  chest  as  in  inspiration ;  the 
arms  should  then  be  brought  down  to  the  sides,  the  elbows 


Fig.  118. — Artificial  respiration:  second  movement,  expiration  (Murray). 

meeting  almost  over  the  pit  of  the  stomach  (Fig.  118)  ;  press- 
ure is  then  made  against  the  chest-wall,  producing  contrac- 
tion of  the  chest ;  the  arms  are  to  be  held  in  the  latter  position 


A  SPII YXIA  TION.  423 

a  few  seconds,  and  then  the  movements  are  repeated.  I'"rom 

twelve   to   fifteen   respirations  will  be  sufficient.     'I'hc  mouth 
must  be  kept  open  and  the  tongue  be  held  forward. 


Fig.  119. — Artificial  respiration:  expiration,  assistant  exerting  pressure  on 
the  chest  (Murray). 

Asphyxiation  from  Smoke. — To  pass  through  sulphur 
fumes  or  smoke,  one  should  hold  a  wet  towel,  a  large  wet 
handkerchief,  or  a  wet  cloth  over  the  nose  and  mouth.     The 


Fig.  120. — Expressing  water  from  the  stomach  and  lungs  (Murray). 

suffocation  should  be  treated  by  artificial  respiration  and  the 
use  of  stimulants,  and  any  coincident  burns  should  be  cared 
for. 


424  APPENDIX. 

Asphyxiation  from  the  inhalation  of  illuminating  gas 

requires  speedy  removal  into  the  pure  air,  artificial  respiration, 
the  inhalation  of  oxygen,  stimulants,  and  the  general  treatment 
for  suffocation. 

Head-accidents. — For  all  accidents  to  the  head,  the  part  is 
to  be  bathed  with  warm  water  and  firm  pressure  with  a  clean 
compress  be  made  until  the  arrival  of  a  physician.  Concus- 
sion of  the  brain  is  the  sudden  interruption  of  the  functions 
of  the  brain  brought  on  by  severe  blows  on,  or  by  other  in- 
jury to,  the  head.  In  the  simple  form  of  concussion  the 
patient  is  partly  insensible,  the  pupils  are  contracted,  and  the 
face  is  pale.  In  a  few  moments  he  may  regain  consciousness  ; 
there  are  nausea  and  vomiting  and  headache.  In  a  severe 
case  of  brain-concussion  death  may  very  soon  occur.  Com- 
pression of  the  brain  is  due  to  tumors,  to  depression  of  the 
skull  from  fracture,  and  to  other  causes.  The  symptoms  closely 
resemble  those  of  apoplexy. 

In  both  these  injuries,  until  the  arrival  of  a  physician,  who 
should  be  sent  for  at  once,  the  patient  should  be  placed  in 
bed  with  the  head  slightly  raised  ;  the  room  should  be  dark- 
ened and  cold  applied  to  the  head.  If  there  is  shock,  heat 
is  to  be  applied,  but  stimulants  are  not  to  be  given  without 
orders  from  the  medical  attendant. 

Epileptic  Convulsion. — A  person  seized  with  an  epileptic 
fit  should  be  placed  in  a  safe  position  on  the  ground  or  floor, 
with  the  clothes  loosened  and  a  pillow  or  cushion  placed  under 
the  head ;  he  should  be  left  so  until  the  fit  is  over.  Some- 
thing should  be  placed  between  the  teeth,  to  prevent  the 
tongue  being  bitten. 

Convulsions  in  children  may  be  due  to  indigestion,  pin- 
worms,  etc.,  or  to  brain-excitement  in  rickets  or  to  irritation 
of  the  nerve-centers  in  teething.  A  great  number  of  the 
diseases  of  children  are  ushered  in  with  convulsions,  which 
take  the  place  of  the  initial  chill  in  the  adult.  They  may 
come  on  suddenly  or  gradually. 

The  child  should  be  put  into  a  hot  bath  (at  a  temperature 
of  from  ioo°  to  104°  F.),  without  waiting  to  undress  it, 
which  can  be  done  in  the  water.  The  head  should  be  kept 
raised  and  cold  applied  to  it.  The  hot-water  bath  will  dilate 
the  blood-vessels  of  the  body,  thus  diverting  the  blood  from 
the  brain  to  the  body.  If  the  attack  is  the  beginning  of  any 
of  the  eruptive  diseases,  the  heat  will  also  bring  out  the  rash, 
besides  relieving  any  pain  in  the  abdomen  or  elsewhere.    The 


POISONING.  425 

child  is  to  1)C  kc])l  in  liic  balh  alxjiiL  live  ininutcs,  .-ind  is  tlicn 
taken  out  and  wrapped  in  a  warm  blanket ;  an  enema  is  given 
to  clear  the  bowels.  A  physician  should  be  summoned  at 
once. 

In  hemorrhage  of  the  lungs  ( hemoptysisj  the  bUjod 
is  bright  red  and  frothy,  from  its  admixture  with  air.  \\\ 
treating  hemoptysis  the  head  and  shoulders  are  elevated  and 
an  ice-bag  or  au  ice-poultice  is  api)lied  to  the  chest  ;  crushed 
ice  may  be  given  the  patient  to  swallow.  Ec^ual  parts  of 
vinegar  or  lemon-juice  and  water,  given  in  teaspoonful  do.ses, 
or  a  quarter  of  a  teaspoonful  of  dry  salt,  may  assist  in  con- 
tracting the  blood-vessels.  Rest  and  quiet  should  be  rigor- 
ously enforced. 

Bleeding  from  the  stomach  (hematemesis)  is  treated 
similarly.  The  blood  may  be  vomited,  and  the  dark-red 
fluid  may  contain  food  \  or  it  may  be  passed  by  the  bowel. 
The  throat  and  nose  should  be  carefully  examined,  as  the 
hemorrliage  may  have  originated  in  these  parts  and  been 
subsequently  vomited. 

In  nosebleed  (epistaxis)  the  head  and  arms  should  be  ele- 
vated, and  pressure  with  the  fingers  should  be  made  on  the 
nostril  from  which  the  blood  is  coming,  or  a  small  piece  of 
lemon  or  a  small  piece  of  cotton  wrung  out  of  vinegar  and 
inserted  will  contract  the  blood-vessels.  The  patient  should 
not  blow  the  nose,  as  it  will  disturb  the  formation  of  clots. 
Ice  may  be  applied  to  the  back  of  the  neck  and  to  the  fore- 
head. 

POISONING. 

Precautions  in  the  Household  Use  of  Poisons. — Acci- 
dental poisoning  often  arises  from  the  administration  of  medi- 
cines from  the  wrong  bottle.  It  is  of  great  importance  that 
all  bottles  in  the  house  containing  liniments,  washes,  disin- 
fectants, etc. ,  that  are  likely  to  be  poisonous  when  taken  in- 
ternally, should  be  kej^t  in  dark-glass  bottles  and  prominently 
labeled,  and,  in  addition,  marked  ''for  external  use  only," 
"poison,"  or  some  other  warning  inscription,  so  that  no 
member  of  the  household  may  use  them  internally  by  mis- 
take. 

The  first  treatment  in  all  cases  of  poisoning,  except 
those  caused  by  very  corrosive  substances,  such  as  strong 
acids  and  alkalis,  is  evacuation  of  the  stomach-contents.  This 
may   be   accomplished   by   emetics,    the   stomach-pump,    or 


426  APPENDIX. 

siphon-tube.  Before  the  arrival  of  medical  aid  there  may- 
be administered  a  large  tablespoonful  of  mustard  in  a  tumbler 
of  warm  water,  or  a  solution  of  table-salt  and  warm  water, 
not  over  one-half  pint  at  a  time,  to  avoid  paralytic  distention 
of  the  stomach-walls.  These  are  very  efficient  household 
emetics,  and  may  be  assisted  by  tickling  of  the  throat  with 
either  the  finger  or  a  feather.  After  vomiting,  the  patient 
should  drink  large  amounts  of  milk  or  water,  and  the  bowels 
should  be  emptied  as  soon  as  possible.  Ordinarily,  any  vom- 
ited matter  should  be  preserved  for  the  physician's  inspec- 
tion. 

If  there  are  symptoms  of  collapse,  such  as  weakness  of 
pulse,  feeble  breathing,  coldness  ,of  the  body,  insensibility, 
etc.,  the  patient  should  be  given  stimulants,  such  as  aromatic 
spirits  of  ammonia,  strong  hot  coffee,  strong  hot  beef-tea, 
brandy,  or  inhalations  of  smelling  salts,  ammonia,  etc.  He 
should  be  placed  on  his  back,  and  be  suiTounded  with  hot- 
water  bottles  and  covered  with  blankets.  Artificial  respira- 
tion, which  is  referred  to  elsewhere  (p.  421),  should  be  insti- 
tuted if  the  breathing  is  very  feeble  or  has  entirely  ceased. 

The  stomach-pump  consists  of  a  long  pipe  with  a  branch 
at  right  angles,  and  is  so  constructed  that  fluid  can  be  pumped 
into  and  out  of  the  stomach  as  desired,  and  so  the  organ  can 
be  thoroughly  washed  out.  The  siphon-tube  is  a  long  piece 
of  rubber  tubing  with  a  glass  funnel  attached  to  one  end. 
The  tube  is  passed  into  the  stomach,  and  the  funnel  raised 
above  the  patient's  head.  Warm  or  tepid  fluid  is  now  poured 
down  the  tube,  and  when  filled  the  end  of  the  tube  is  brought 
down  to  a  lower  level  than  the  patient's  stomach,  when  the 
stomach-contents  flow  out  by  siphon  action.  This  is  repeated 
until  the  fluid  returns  clear. 

The  irritant  poisons  act  on  the  stomach  and  bowels, 
and  the  symptoms  of  all  such  poisons  are  generally  the  same. 
Coming  in  contact  with  the  lips,  mouth,  throat,  and  stomach, 
they  produce  a  burning  sensation  and  give  rise  to  vomiting  and 
pain  in  the  stomach  and  abdomen,  the  pain  being  increased 
upon  pressure  and  by  purging.  The  effects  of  the  poisons 
are  chiefly  upon  these  organs,  which  they  irritate  and  influ- 
ence. After  all  irritant  poisons,  demulcent  drinks,  such  as 
flaxseed  tea,  white  of  eggs,  glycerin,  sweet  oil,  starch-water, 
or  warm  milk,  should  be  given  to  soothe  the  inflamed  mucous 
membrane. 

Strong  acids  and  alkalis,  by  their  destructive  action  on 


POISONING.  A.I'J 

the  tissues,  may  cause  dcalh.  Oil  of  vitriol  (sulphuric  acid), 
which  may  be  taken  as  an  example  of  this  class,  is  occasion- 
ally taken  by  children  or  drunkards.  Such  a  [joison  produces 
immediate  symptoms — a  burning  pain  in  the  mouth,  which 
becomes  white  all  over,  vomiting,  and  collapse.  If  death 
does  not  rapidly  occur,  it  may  supervene  later  from  perfora- 
tion of  the  stomach  as  a  result  of  the  ulceration  produced. 

A  ]:)owerful  and  not  uncommon  poison  is  oxalic  acid,  pojni- 
larly  known  as  acid  of  sugar.  The  destructive  ac;tion  is  not 
so  marked  as  in  the  case  of  the  stronger  acids,  such  as  sulphuric 
and  nitric.  A  burning  taste  in  the  mouth  and  pain  in  the 
stomach,  with  acid  brownish  vomit  and  marked  collapse,  are 
present.  It  rapidly  causes  death.  No  emetic  should  be 
given,  but  mild  alkalis  must  be  administered,  and  the  collapse 
promptly  treated. 

In  all  cases  of  poisoning  by  acids  we  give  alkalis  (mild), 
such  as  chalk,  magnesia,  or  common  washing-soda,  which  we 
may  find  in  nearly  every  house.  Flour-and-water  is  a  good 
mixture.  When  an  alkali  has  caused  symptoms  of  poisoning, 
the  readiest  remedy  at  hand  is  usually  vinegar.  Olive  oil 
may  be  given. 

Narcotic  poisons  act  upon  one  or  more  parts  of  the  ner- 
vous system,  producing  headache,  giddiness,  numbness,  stupor, 
and  paralysis,  and  often  convulsions  and  death.  They  have 
not  the  burning  taste  of  irritants,  and  rarely  give  rise  to  vomit- 
ing and  purging. 

Opium  is  used  in  many  medicines  and  substances  commonly 
kept  in  the  household.  Besides,  it  is  a  substance  which  is 
often  taken  habitually  in  various  forms  by  some  member  of 
the  family. 

A  patient  the  subject  of  poisoning  by  opium  or  morphin 
generally  presents  certain  well-marked  symptoms.  At  first 
there  is  a  great  tendency  to  sleep,  with  deep  breathing, 
flushed  face,  and  moist  skin.  The  patient  may  often  now  be 
roused,  but  soon  relapses  into  his  former  condition.  As  the 
symptoms  progress  it  becomes  impossible  to  rouse  him.  The 
breathing  becomes  irregular,  the  pulse  feeble,  and  the  pupils 
pin-point.  There  is  a  cold,  clammy  sweat.  If  death  does 
not  occur  in  twelve  hours  after  the  poison  has  been  introduced 
into  the  body,  there  is  a  good  prospect  of  recovery.  There  is 
often  great  difficulty  in  deciding  whether  the  sym]itoms  are 
due  to  opium-poisoning,  apoplexy  (hemorrhage  into  the  brain), 
alcoholism,  or  uremia. 


428  APPENDIX. 

In  the  treatment  of  opium-poisoning-,  in  addition  to  the 
general  treatment  of  poisoning,  it  is  necessary  to  rouse  the 
patient  and  prevent  sleep  by  every  possible  means.  A  good 
plan  is  to  walk  the  patient  about  at  short  intervals ;  for  this 
two  persons  are  generally  required,  one  on  each  side.  Slap- 
ping the  body  with  wet  towels  is  also  useful.  The  electric 
battery  may  be  applied  at  short  intervals.  In  advanced  cases 
artificial  respiration  may  be  necessary,  also  stimulation  of  the 
heart  by  the  battery.  Strong  hot  coffee  is  a  valuable  and 
easily  obtained  remedy  which  must  always  be  given  ;  it  may 
be  administered  by  the  mouth,  stomach-tube,  or  by  the  rectum. 

Belladonna,  or  deadly  nightshade,  and  its  active  ingre- 
dient, atropin,  are  powerful  narcotic  poisons,  often  kept  in 
households  in  the  forms  of  liniments,  eye-drops,  etc.  In  cases 
of  belladonna-poisoning  the  pupils  are  dilated,  and,  unlike 
in  poisoning  by  opium,  the  patient  shows  evidence  of  noisy 
delirium,  which  attracts  attention  ;  hence,  recovery  is  more 
frequent  than  in  opium-poisoning.  In  addition  to  general  meas- 
ures there  may  be  cold  affusions  applied  to  the  head  and  face. 

Alcohol  is  another  common  narcotic  poison.  Acute  alco- 
holic poisoning  often  presents  alarming  symptoms,  and  death 
may  occur  rapidly.  The  symptoms  are  frequently  very  simi- 
lar to  those  of  advanced  opium-poisoning.  The  breath  usually 
smells  of  alcohol ;  but  this  is  not  reliable,  as  alcohol  is  often 
given  to  relieve  symptoms  which  may  be  due  to  another  cause. 
These  cases  should  be  treated  by  emptying  the  stomach  and 
the  application  of  cold  affusions  to  the  face,  with  stimulation  of 
the  body  by  warmth  and  hot  drinks.  A  mustard-plaster  may 
also  be  applied  to  the  nape  of  the  neck. 

Prussic  acid  is  a  most  virulent  poison,  often  taken  for  sui- 
cidal purposes.  It  produces  rapid  insensibility.  The  patient 
lies  on  the  ground,  with  staring  eyes  and  dilated  pupils. 
Breathing  is  slow  and  irregular,  and  the  pulse  is  feeble  or 
even  absent.  The  rapidity  of  the  onset  of  the  symptoms, 
together  with  the  peculiar  penetrating  almond-like  odor  of 
the  breath,  often  enables  us  to  detect  poisoning  by  this  sub- 
stance. Where  convulsions  occur,  the  symptoms  may  resem- 
ble those  of  epilepsy.  In  the  management  of  a  case  of 
prussic-acid  poisoning  the  greatest  promptitude  is  necessary. 
Cold  water  poured  over  the  head  and  back  is  the  best  remedy, 
and  one  always  at  hand.  It  acts  by  rousing  the  respiratory  func- 
tions. Artificial  respiration  must  be  kept  up  perseveringly.  In 
fatal  cases  death  generally  occurs  in  half  an  hour  or  less. 


POISONING.  429 

Strychnin,  the  active  ingredient  of  the  mix  voniiea  seed,  is 
sonietinies  given  or  taken  as  a  poison.  It  is  often  a  poisonous 
constituent  of  rat-poison.  'I'lie  chief  symptoms  of  strychnin- 
poisoning  consist  of  muscular  sjjasms  and  convulsions.  'I"hc 
body  becomes  stilfened  and  arched.  Unlike  tetanus  (lock- 
jaw), the  jaws  are  affected  later.  The  fits  cease  altogether 
for  a  minute  or  two,  to  return  on  the  slightest  ])rovocation. 
Death  usually  results  from  exhaustion.  In  such  cases  emetics 
should  be  administered  and  cold  affusions  should  be  avoided. 
To  relieve  the  spasms,  it  is  usually  necessary  to  place  the 
patient  under  chloroform.  The  slightest  noise  or  excitement, 
which  may  bring  on  or  increase  the  spasms,  should  be  pre- 
vented. 'I'he  strength"  must  be  supported  by  all  the  means  in 
our  power.      Artificial  respiration  may  be  re(}uired. 

The  following  table,  by  Crozer  Griffith,  gives  the  more  im- 
portant points  in  the  management  of  the  commoner  forms  of 
acute  poisoning  : 

Table  of  Poisons  and  Antidotes. 

Poison.  Antidotes, 

...             .       ,     J       i_i     •  r  '"i"  alkali,  such  as  magnesia,  chalk,  whiting, 

Acid      acetic,    hydrochlonc,  I        ^^^                   followed  by  soothing  drinks 

sulphuric,  mtnc.  |      or  sweet  oil. 

Acid,  carbolic;  creasote    .    .  .  jB/jf)?^  J;?// in  abundance  ;  soap  ;  no  oil. 

.    .  ,               ,.           •     ,    J.  {  Emetic,  followed  by  lime  (as  chalk,  plaster, 

Acid,        o.^alic,        including  ■        ,,hiting)  or  magnesia,  but  not  by  potash 

salts  of  lemon.  |      ^^  ^^^-^.  ^^^^^  soothing  drinks. 

J  Fresh    air;       ammonia     to    nostrils;     cold 
Acid,  prussic |       louche  ;  artificial  respiration. 

f  Emetic,    followed   by    digitalis;    no   pillow 
Aconite |       under  head ;  free  stimulation. 

.,,,,,  ,        ^    ,  f  Emetic  ;  cold  douche  on  head  ;  warmth  and 

Alcohol  (brandy,  etc.).     .    .     j       artificial  respiration. 

Alkalis  (as  ammonia,  spirits   f   y;„  „^   lamw-juicc ,  followed  bv  sooth- 

of  hartshorn,  lye,    caustic  i„|  brinks  or  sweet  oil. 

potash).  (.  * 

f  Emetic  if  vomiting  is  not  already  profuse  ; ' 
,  -1  then   tannic   acid   freely    or    strong    tea ; 

Antimony   (tartar    emetic)  .    \       j^^.     ^^^jj,.    ^^    ^jj^^,.    soothing  ;  dnnks  at 

[  finally  castor  oil  to  empty  the  bowels. 

f  Emetic,    quickly    followed   by  plenty    of   a 

I  fresh    mixture  of  the   tincture    of  chlorid 

Arsenic    (Fowler's    solution,    j  'of  iron  with  calcined  magnesia,  icashing- 

Paris   green,    "  Rough  on  -j  or  fiaking-soda,  or  'cvatcr  of  ammonia,  or 

Rats").                                       I  I'v  Jeaunel's  antidote.     Then  white  of  egg, 

I  soothing  drinks,  or  sweet  oil ;  castor  oil  to 

[  empty  bowels, 


430  APPENDIX. 

Atropin  (see  Belladonna). 

f  Emetic  ;  tannic  acid  freely  ;   cold  to  head ; 
Belladonna  (atropin)     •    •    ■     j       coffee.     Stimulants  and  warmth  if  needed. 

Blue  stone;  blue  vitriol  (see  Copper). 

Chloral Treatment  as  for  opium-poisoning. 

.  ,    ,   J  f  Cold   douche  ;   friction  of  skin ;  inversion ; 

Chloroform,  mhaled.     ■    •    •    \       artificial  respiration. 

(■  Emetic,  followed  by  white  of  egg  or  milk, 
Copper    (blue     stone;     blue)       ygUow  prussiate  of  potash  ;  'Ca&w -,oo\!c{mg 
vitriol;  verdigris).  |      -<^r\r{^s. 

(■  Emetic,  followed  by  white  of  egg  or  milk ; 
Corrosive  sublimate  .    .    .    .    ^       soothing  drinks ;  tannic  acid  freely  ;  castor 
(_       oil  to  open  bowels. 

Cyanid  of  potash  (see  Acid,  prussic). 
Fowler's  solution  (see  Arsenic). 

Gas  (illuminating   gas,  coal-   f  Fresh  air;    artificial  respiration;    ammonia 
gas).  (       to  nostrils ;  cold  douche. 

f  Starch    or  flour   mixed   with    water,   given 
lo'^^'^ j       freely  ;  emetic  ;  soothing  drinks. 

Laudanum  (see  Opium). 

,  f  Emetic,  followed  by  Epsot)i  salt ;  white  of 

Lead  (sugar-of-lead)    •    •    •    |      ggg  or  milk ;  alum. 

Matches  (see  Phosphorus). 

Morphin  (see  Opium). 

Nux  vomica  (see  Strychnin). 


Opium  (including  lauda- 
num, morphin,  paregoric 
soothing  syrups,  etc.). 


Emetic  (but  generally  useless)  ;  pei-manga- 
nate  of  potash  in  doses  of  4  or  5  grains  if 
case  is  seen  early  ;  strong  coffee  ;  atropin  ; 
keep  patient  awake  and  breathing  by  cold 
douche  to  head  and  spine,  walking,  etc., 
but  not  to  extent  of  exhaustion  ;  artificial 
respiration. 
Paregoric  (see  Opiuni). 
Paris  green  (see  Arsenic). 

^,        ,  /       X  ,_  I.      J       r  Emetic ;     then  permanganate   of  potash   in 

Phosphorus      (match-heads,  doses  of  4  01-5  grains  well  diluted;  then 

some  roach   and  rat  poi-  \       ^^^^^  ^^^^  ^^  magnesia  to  open  bowel, 
^^^^^^^  [      but  no  milk  or  oil  of  any  kind. 

Poisonous     plants     (Jimson  f  ^^^^       followed   by    tannic   acid ;    strong 
weed,     poisonous     mush-  ^^^^^  ^^   ^^^^^    j'  ^j^^^nia  to   nostrils ; 

rooms,       deadly        night-  external  warmth ;  artificial  respiration, 

shade,  tobacco,  etc.).  l_ 

Prussic  acid  (see  Acid,  prtcssic). 

,.  >     f   Table-salt,   followed    by   emetic;    milk     or 
Silver  nitrate  (lunar  caustic).  {       ^^j^^  ^^  ^^^^_ 

„.,,,.,  f  Emetic,  followed  by  castor  oil  as  a  purga- 

Spoiled  food |       ^j^^^ 

„        ,     .     ,  .     ,  f  Emetic,  followed  by  tannic  acid,  bromid  of 

Strychnm  (nux  vomica)    .    .    j       ^^/^^/,  freely,  or  chloral. 

Tartar  emetic  (see  Antintony). 


GLOSSARY. 


Abdomen.     The  belly. 

Abdominal.  Pertaining  to  the 
belly. 

Accommodation.  Adjustment  of 
the  eye  for  various  distances. 

Adenoid.  A  tumor  composed  of 
glandular  tissue. 

Advancement.  Detachment  of 
an  eye-muscle  and  reattachment  at 
an  advanced  point. 

Aeration.  Purification  by  expo- 
sure to  air. 

Afferent.  Passing  or  conducting 
from  the  periphery  or  the  nerve- 
center. 

Albinism.  A  congenital  deficiency 
of  coloring-matter  in  the  skin,  hair, 
etc. 

Alimentary  canal.  The  entire 
digestive  tract  from  the  mouth  to  the 
anus. 

Alveolus.  A  small  hollow,  as  a 
socket  of  a  tooth. 

Amblyopia.      Dimness   of  vision. 

Ametropia.  Imperfection  in  the 
refraction  of  the  eye. 

Anemia.  Deficient  quantity  or 
quality  of  the  blood. 

Aneurysm.  A  sac  formed  by  the 
dilation  of  part  of  an  artery  and 
filled  with  blood. 

Anisometropia.  Marked  inequal- 
ity in  the  refractive  power  of  the  two 
eyes. 


Antiseptic.  A  substance  that 
destroys  germs. 

Antrum  of  Highmore.  A  cavity 
in  the  upper  jaw,  communicating 
with  the  nose. 

Anus.  The  external  opening  of 
the  lower  bowel  (rectum). 

Appendix.  See  Vermiform  ap- 
pendix. 

Aqueous  humor.  A  watery  fluid 
occupying  that  portion  of  the  eyeball 
between  the  cornea  and  the  crystal- 
line lens. 

Arcus  senilis.  A  whitish  ring 
occurring  on  the  cornea,  particularly 
in  the  aged. 

Arytenoid  cartilages.  Two  carti- 
lages at  the  back  of  the  larynx. 

Aspergillus.  A  genus  of  fungi 
(moulds). 

Asphyxiation.  The  act  of  caus- 
ing suffocation. 

Asthenopia.  A  weakness  and 
speedy  tiring  of  the  visual  apparatus. 

Astigmatism.  A  defect  of  the 
eye  in  which  the  light-rays  are  not 
brought  to  a  proper  focus.  A  point 
of  light  is  seen  as  a  star. 

Atrophy.  A  wasting  away  of  a 
part. 

Auditory  canal.  The  passage 
that  leads  from  the  external  ear  to 
the  ear-drum. 

Auditory  nerve.  The  nerve  of 
hearing. 

Auricle,     i.  The  external  ear.    2. 

431 


432 


GLOSSARY. 


The  two  upper  chambers  of  the 
heart. 

Aurist.     Specialist  in  ear-diseases. 

Auto-intoxication.  Poisoning  by 
some  toxic  or  effete  substance  formed 
within  the  body. 

Axilla.     The  armpit. 

B 

Binocular  vision.  Normal  simul- 
taneous use  of  the  eyes. 

Blepharitis.  Inflammation  of  the 
edges  of  the  eyelids. 

BroncM.  The  two  main  branches 
of  the  windpipe  (trachea). 


Canaliculus.  A  small  canal,  as 
the  lacrimal  canaliculus,  through 
which  the  tears  drain  into  the  nose. 

Canthus.  The  angle  at  the  junc- 
tion of  the  eyelids;  the  "corner  of 
the  eye." 

Capillary.  Any  one  of  the  hair- 
like vessels  which  conduct  the  blood 
from  the  arteries  to  the  veins. 

Capsule  of  Tenon.  The  sheath 
enveloping  the  eyeball. 

Cardia.  The  opening  of  the 
esophagus  (gullet)  into  the  stomach. 

Caries.  Decay  of  bone ;  dental 
caries,  decay  of  teeth. 

Cartilage.     Gristle. 

Cataract.  Opacity  of  the  crystal- 
line lens  of  the  eye. 

Cecum.  The  upper  part  of  the 
large  intestine. 

Cement.  The  hard  layer  cover- 
ing the  root  of  a  tooth. 

Central  nervous  system.  Brain 
and  spinal  cord. 

Cerebral  anemia.  Deficient 
blood-supply  to  the  brain. 


Cerebrum.     The  brain  proper. 

Cerumen.     Ear-wax. 

Cholesteatoma.  An  encysted 
tumor  containing  cholesterin. 

Choroid.  The  coat  of  the  eyeball 
containing  the  blood-vessels. 

Choroiditis.  Inflammation  of  the 
choroid. 

Chyme.  Food  which  has  under- 
gone digestion  in  the  stomach. 

Cilia.  I.  Eyelashes.  2.  A  small 
lash-like  process. 

Ciliary  body.  The  pigmentary 
coat  of  the  eye. 

Ciliated  epithelium.  Epithelium 
provided  with  small  hairs  constantly 
in  motion. 

Clavicle.    Collar-bone. 

Colon.  The  middle  part  of  the 
large  intestine  between  the  rectum 
and  the  cecum. 

Coma.  Morbid  sleep  or  uncon- 
sciousness, as  the  uremic  coma  of 
disease  of  the  kidneys. 

Commissure.  The  line  of  junc- 
tion between  two  similar  intersecting 
surfaces,  as  commissure  of  the  eye- 
lids. 

Compress.  Folded  cloth  for  apply- 
ing pressure. 

Cones.  Cone-shaped  bodies  of 
the  retina. 

Conjunctiva.  Membrane  which 
lines  the  eyelids  and  covers  the  eye- 
ball. 

Conjunctivitis.  Inflammation  of 
the  conjunctiva. 

Cornea.  The  transparent  front 
part  of  the  eyeball. 

Cortical  centers.  Nerve-centers 
of  the  cerebrum  (brain  proper). 

Costal  cartilages.  Cartilages 
which  prolong  and  attach  the  ribs  to 
the  breast-bone  (sternum). 


GLOSSARY. 


433 


Cribriform  plate.  Tlic  upper  per 
foratcd  plalr  ol  llir  clliinoid  bone. 

Cricoid  cartilage.  'I  lie  lowest 
cartilage  of  the  larynx. 

Crystalline  lens.  The  transparent 
lenticular  organ  behind  the  pupil. 

Curarizatlon.  Muscular  weak- 
ness and  paralysis  similar  to  that 
produced  by  a  drug  called  curare. 

Cuticle.  The  outermost  layer  of 
skin. 

Cyanosis.  Blueness  of  skin  or 
other  tissues. 

Cycloplegia.  Paralysis  of  the 
ciliary  muscle  of  the  eyeball. 

D 

Dacryocystitis.  Inflammation  of 
the  tear-bag. 

Deglutition  The  act  of  swallow- 
ing. 

Dejecta.  The  waste  matter  passed 
from  the  bowel ;  the  feces. 

Dentin.  A  brittle  substance  form- 
ing the  main  part  of  the  tooth. 

Depilatory.  Having  the  power 
of  removing  hair. 

Derma  cutis.  The  true  skin ; 
the  skin  underneath  the  epidermis. 

Dermatologist.  A  specialist  on 
diseases  of  the  skin. 

Desquamation.  Shedding  of  the 
skin. 

Diabetes.  A  disease  marked  by 
an  excessive  secretion  of  urine,  gen- 
erally loaded  with  glucose  (sugar). 

Diaphragm.  The  partition  which 
separates  the  chest  from  the  abdomen. 

Diathesis.  Predisposition  to  dis- 
ease. 

Diplopia.  The  seeing  of  single 
objects  as  double. 

Douche.      A   stream    of  water  or 
other  fluid  directed  against  a  part. 
28 


Duct.  A  tube  through  whicfi  the 
seerelion  of  a  gland  empties. 

Duodenum.  I  he  first  jjart  of  the 
small  intestine,  beginning  at  the 
stomach. 


EflB.eurage.  Centripetal  stroking 
movenirnt  in  massage. 

Elastic  fibers.  Fibers  that  com- 
post' tissue  capable  of  returning  to  its 
proper  shape  after  compression  or 
stretching. 

Emetic.  A  substance  that  causes 
vomiting,  as  ipecac. 

Emmetropia.  Perfect  visual  re- 
fraction ;  normal  vision. 

Emphysema.  Abnormal  disten- 
tion of  tissue  by  air  or  gas,  generally 
applied  to  distended  lung  tissue. 

Enteroptosis.  A  downward  dis- 
placement of  the  intestines. 

Entropion.  Turning  in  of  the  eye- 
lids or  eyelashes. 

Enucleation.  Removal  from  an 
envelope.  Eiiucleation  of  the  eye- 
ball is  the  cutting  out  of  that  organ 
from  its  membranous  envelopes. 

Epidermis.  The  outermost  layer 
of  skin. 

Epiglottis.    The  lid  of  the  larynx. 

Epiphora.     Overflow  of  tears. 

Epistaxis.  Bleeding  from  the 
nose. 

Epithelium.  The  outer  and  blood- 
less layer  of  mucous  membranes  and 
of  the  skin. 

Erectile  tissue.  Spongy  tissue 
that  becomes  hard  when  expanded 
with  blood. 

Ergograph.  Instrument  for 
measuring  work  done  by  muscular 
action. 

Esophagus.   The  canal  which  car- 


434 


GLOSSARY. 


ries  the  food  from  the  throat  into  the 
stomach.     The  gullet. 

Ethmoid  bone.  A  sieve-like  bone 
of  the  nose. 

Eustachian  tube.  One  of  two 
canals  leading  from  the  back  of  the 
nose  to  the  drum  of  the  ear. 

Exantbematous.  Characterized 
by  an  eruption  or  rash.  The  exan- 
themata are  the  rash-diseases,  such 
as  measles,  chicken-pox,  scarlet 
fever,  etc. 

Excrescence.  A  morbid  growth 
projecting  from  a  surface. 

Exostosis.  Abnormal  outgrowth 
from  surface  of  bone. 

Extravasation.  The  escape  of 
any  fluid  from  its  proper  vessel  into 
the  tissue. 


Fauces.  The  communication  be- 
tween the  throat  and  pharynx. 

Feces.  Refuse  material  expelled 
from  the  bowels  through  the  anus. 

Fibroid  phthisis.  Interstitial 
pneumonia ;  chronic  bronchitis. 

Fossa.  A  pit,  depression,  or  hol- 
low. 

Fovea  centralis.  Pit  in  middle 
of  macula  lutea  ;  the  sight-center  of 
the  retina. 

Frontal  bone.  The  bone  of  the 
forehead. 

G 

Gastric  juice.  The  digestive  fluid 
secreted  by  the  stomach-glands. 

Gastro-intestinal  tract.  The 
stomach  and  intestines.  The  bowels 
or  gut. 

GenitO-urinary.  Pertaining  to 
the  genital  and  urinary  organs. 


Germicide.  An  agent  that  de- 
stroys microbes. 

Glands.  Small  organs  occurring 
in  different  parts  of  the  body  and 
secreting  fluids. 

Glaucoma.  Excessive  pressure 
within  the  eye,  leading  to  partial  or 
complete  blindness.  Hardening  of 
the  eyeball. 

Glottis.  Aperture  between  the 
vocal  cords. 

Glucose.  Grape-sugar,  found  nor- 
mally in  the  animal  body  and 
abnormally  in  the  urine  in  diabetes 
(glycosuria). 

Glycogen.  A  carbohydrate  from 
liver  and  other  tissues. 

H 

Hair-follicle.  The  small  depres- 
sion in  the  skin  from  which  each 
hair  grows. 

Hard  palate.  Front  part  of  the 
roof  of  the  mouth. 

Hematemesis.  Vomiting  of  blood. 

Hematoma.  A  tumor  containing 
blood. 

Hemoglobin.  The  coloring-mat- 
ter of  red  corpuscles  of  the  blood. 

Hemoptysis.  Spitting  of  blood 
coming  from  the  lungs,  as  in  phthisis 
or  consumption  of  the  lungs. 

Hepatic.       Pertaining  to  the  liver. 

Heterophoria.  Absence  of  paral- 
lelism between  visual  fields.  Ab- 
normality of  ocular   muscle-balance. 

Holophane.  A  lamp-globe  formed 
of  prisms  to  deflect  the  light  rays 
downward. 

Humor.  Any  fluid  or  semifluid 
of  the  body. 

Hutchinson  teeth.  A  character- 
istic condition  of  the  teeth  seen  in 
hereditary  syphilis. 


GI.OSSAKV. 


435 


Hydrotherapy,  'rnjiinuiu  of  dis- 
ease l(y  means  (ji  w;itcr. 

Hyperopia.     Far-sightedness. 

Hyperostosis.  Excessive  growth 
of  bone. 

Hypertrophy.  Enlargement  of  a 
]iaii. 

Hypochondriasis.  A  mild  form  of 
melancholia. 


I 


Ileocecal  valve.  Valve  at  the 
junction  of  the  small  and  large  in- 
testines. 

'Ileum.  The  last  portion  of  the 
small  intestine,  joining  the  cecum. 

Immunity.  The  condition  of  being 
protected  against  any  particular  dis- 
ease, as  from  small-pox  by  vaccina- 
tion. 

Incuhation.  The  period  between 
the  implanting  of  an  infectious  dis- 
ease and  its  manifestation. 

Insalivation.  Saturation  of  food 
with  saliva  during  mastication. 

Insomnia.     Inability  to  sleep. 

Interstitial  tissue.  The  con- 
nective tissue  between  the  cellular 
elements  of  the  body. 

Intestine.  That  part  of  the  ali- 
mentary canal  extending  from  the 
stomach  to  the  anus.  The  bowd 
or  gut.  The  first  portion  is  the  j-;;?!?// 
intestine  ;  the  second,  and  larger,  is 
the  li^yge  intestine. 

Iridocyclitis.  Inflammation  of 
the  iris  and  ciliary  body.\ 

Iris.  The  pigmented  membrane 
behind  the  cornea,  perforated  by  the 
pupil. 

Iritis.       Inflammation  of  the  iris. 

Isthmus  of  fauces.  The  pas- 
sage connecting  the  mouth  and 
pharynx. 


Jejunum.  That  portion  of  the 
small  inti-stine  between  the  duode- 
num and  the  ileum. 

K 

Keloid.     A  tumor  of  the  skin. 
Kyphosis.     A    fore-and-aft   bend- 
ing of  the  spine.     Hunchback. 


Labyrinth.  A  term  applied  to 
the  internal  ear. 

Lacrimal  glands.  The  glands 
which  secrete  the  tears. 

Lacrimal  sac.     The  tear-bag. 

Laryngitis.  Inflammation  of  the 
larynx. 

Laryngopharynx.  The  lower 
portion  of  the  pharynx. 

Laryngoscopic  mirror.  A  mir- 
ror used  to  examine  the  larynx. 

Larynx.  The  organ  from  which 
the  voice-sounds  proceed. 

Lens-capsule.  A  transparent  sac 
that  encloses  the  crystalline  lens  of 
the  eyeball. 

Leukocjrte.  A  white  blood-cor- 
puscle. 

Ligament.  A  tough  band  con- 
necting bones  or  supporting  organs. 

Lobule.     A  small  lobe. 

Locomotor  ataxia.  A  disease 
affecting  the  spinal  cord,  character- 
ized by  partial  paralysis  and  a  pecu- 
liar gait. 

Lunula.  The  crescentic  whitish 
area  near  the  root  of  the  nail. 

Ljnnphatics.  Small  vessels  per- 
vading the  body  and  containing 
lymph. 


436 


GLOSSAI^;Y. 


M 

Macula  lutea.  The  point  of 
clearest  vision  at  the  center  of  the 
retina;  the  yellow  spot. 

Malleus.  A  mallet-shaped  bone 
of  the  middle  ear. 

Mariotte's  blind  spot.  The  spot 
on  the  retina  where  the  optic  nerve 
enters. 

Mastoid.  The  mastoid  or  nipple- 
shaped  process  of  the  temporal  bone 
behind  the  external  ear. 

Meatus  auditorius.  The  passage 
that  leads  from  the  external  ear  to 
the  ear-drum. 

Mechanotlierapy.  Treatment  of 
disease  by  mechanical  means,  as 
rubbing,  massage,  bending,  etc. 

Meibomian  glands.  Oil-secret- 
ing glands  of  the  eyelids. 

Membrane.  A  thin  layer  of  tissue 
covering  a  surface  or  dividing  an 
organ. 

Metabolism.  The  process  by 
vi'hich  the  body-tissues  are  renewed 
and  nourished. 

Micturition.  The  passage  of 
urine;  urination. 

Miotic.  A  drug  which  contracts 
the  pupil,  as  eserin. 

Mucus.  The  secretion  from  mu- 
cous glands. 

Muscse  volitantes.  "  Floating 
flies."  Specks  seen  as  floating  be- 
fore the  eyes. 

Mydriatic.  A  drug  that  dilates 
the  pupil,  as  atropin  (belladonna). 

Myopia.    Near-sightedness. 

N 

Narcotic.  A  drug  that  produces 
sleep  or  stupor  and  relieves  pain,  as 
opium. 


Nares.     The  chambers  of  the  nose. 

Nasal  duct.  The  duct  that  conveys 
the  tears  from  the  tear-bag  into  the 
nose. 

Nasopharynx.  The  part  of  the 
pharynx  above  the  soft  palate. 

Neurasthenia.  Nervous  prostra- 
tion. 

Neuritis.   Inflammation  of  a  nerve. 

Neuromuscular  system.  The 
system  of  muscles  and  their  nerves. 

Nystagmus.  Continuous  move- 
ment of  the  eyeball,  horizontally  or 
rotary. 

o 

Olfactory.  Pertaining  to  the  sense 
of  smell. 

Ophthalmia  neonatorum.  In- 
flammation of  the  outer  membranes 
of  the  eyeball  in  the  newborn. 

Ophthalmoscope.  An  instrument 
for  examining  the  interior  of  the  eye- 
ball. 

Orbit.  Bony  socket  that  contains 
the  eyeball. 

Oropharynx.  The  lower  part  of 
the  pharynx,  which  communicates 
with  the  mouth. 

Ossicle.  A  minute  bone  ;  any  one 
of  the  small  bones  of  the  ear. 

Otorrhea.      A  discharge  from  the 


Palate.  The  roof  of  the  mouth. 
There  is  a  hard  and  a  soft  palate, 
which  see. 

Pantoscopic  spectacles.  Bifocal 
glasses. 

Papilla.  A  small  nipple-shaped 
elevation. 

Paresis,  i.  General  paralysis.  2. 
Incomplete  motor  paralysis. 


GLOSSARY. 


437 


Parotid  gland.  One  of  \\\v.  glands 
wliich  scci'clr  siUiva. 

Pathogenic.      CJausinK  disease. 

Penicilllum.  A  .yc-iuis  nf  mould- 
fun  s^i. 

Peridental  membrane.  I  lie 
membrane  covering  du:  cement  of 
the  tooth. 

Periosteum.  The  membrane  in- 
vesting l)one. 

Peritoneum.  The  membrane 
which  Hues  the  abdominal  walls  and 
invests  the  abdominal  organs. 

Petrissage.  Kneading  Action  in 
massage. 

Peyer's  patches.  Whitish  patches 
of  lymph-foUicles  in  the  small  intes- 
tine. 

Pharyngeal  tonsil.  A  small  body 
situated  in  the  vault  of  the  pharynx. 

Pharynx.  A  musculomembran- 
ous  sac  lying  behind  the  mouth  and 
opening  below  into  the  esophagus. 

Photometry.  Measurement  of 
the  intensity  of  light. 

Photophobia.      A  dread  of  light. 

Phthisis.  Consumption  of  the 
lungs. 

Pigment.    Coloring-matter. 

Pillars  of  fauces.  Folds  of  mu- 
cous membrane  at  the  sides  of  the 
fauces. 

Pinguecula.  Yellowish  spots  on 
the  conjunctiva. 

Plantar  ligaments.  Ligaments  of 
the  sole  of  the  foot. 

Plastic  operation.  An  operation 
for  repairing  injuries  or  deformities 
by  forming  new  parts  from  surround- 
ing tissue. 

Plethora.  A  state  characterized 
by  swelling  of  the  blood-vessels,  due 
to  excess  of  blood. 

Plethysmograph.    An  instrument 


for  measuring  variations  in  size  and 
blood-supjjly  of  a  part. 

Pleura.  The  serous  membrane  in- 
vesiing  th(!  lungs  and  lining  the 
thorax. 

Plexus.  A  network  of  blood-ves- 
sels or  nerves. 

Polyps.  Small  growths  from  a 
mucous  surface,  as  nasal  polyps,  uter- 
ine ]")(;lyps,  etc. 

Presbyopia.  Im[)airment  of  eye- 
sight due  to  hardening  of  the  crystal- 
line lens  in  advanced  life. 

Process.  A  prominence,  espe- 
cially on  a  bone. 

Prophylaxis.  Preventive  •  treat- 
ment. 

Protoplasm.  The  essential  con- 
stituent of  the  living  cell. 

Pruritus.     Itching. 

Pterygium.  A  fleshy  growth  on 
the  conjunctiva. 

Pubes.  The  hair  on  the  external 
genitalia,  or  the  region  covered  with 
it. 

Pulmonary  tuberculosis.  Con- 
sumption of  the  lungs. 

Punctum  lacrimale.  An  orifice 
on  each  lid  leading  into  the  lacrimal 
canaliculus  and  tear-bag. 

Pupil.  The  opening  in  the  center 
of  the  iris. 

Purulent.  Containing  or  consist- 
ing of  pus. 

Pylorus.  The  opening  of  the 
stomach  into  the  small  intestine. 

Pyorrhoea  alveolaris.  Inflam- 
mation of  the  dental  periosteum 
with  discharge  of  pus. 

R 

Rachitis.  A  disease  in  which  the 
bones  become  softened  and  de- 
formed ;  rickets. 


438 


GLOSSARY. 


Eectum.  The  lower  part  of  the 
large  intestine. 

Regurgitation.  The  casting  up 
of  food  just  swallowed. 

Rete  mucosum.  The  innermost 
layer  of  the  outer  skin. 

Retina.  The  perceptive  membrane 
lining  the  inside  of  the  eyeball. 

Retinitis.  Inflammation  of  the 
retina. 

Rhinoscopy.  Examination  of  the 
nose  with  the  aid  of  a  speculum  and 
light. 

Rickets.  A  disease  in  which  the 
bones  become  softened  and  de- 
formed ;  rachitis. 

Ringworm.  A  skin  disease  occur- 
ring in  circular  patches. 

Rods.  Rod-shaped  bodies  of  the 
retina. 


Saliva.  The  fluid  secreted  in  the 
mouth,  an  important  digestive  sub- 
stance. 

Salivary  glands.  Those  glands 
which  secrete  the  saliva. 

Sarcolemma.  Elastic  sheath  that 
encloses  each  fiber  of  striated  mus- 
cle. 

Scapula.     Shoulder-blade. 

Sclera.  The  membrane  which, 
with  the  cornea,  forms  the  external 
coat  of  the  eyeball. 

Scoliosis.  Lateral  curvature  of 
the  spine. 

Scorbutus.  A  disease  due  to  im- 
proper food  ;    scurvy. 

Scotoma.  A  blind  or  partly  blind 
area  in  the  field  of  vision. 

Sebaceous  glands.  The  glands 
which  secrete  the  oil  which  lubricates 
the  skin. 


Semilunar  area.  The  crescentic 
white  area  near  the  root  of  the  nail. 

Septum.  A  dividing  wall  or  parti- 
tion, as  the  nasal  septum. 

Sesamoid  bone.  A  small  flat  bone 
occurring  in  a  tendon  playing  over  a 
bony  surface. 

Sigmoid  flexure.  That  part  of  the 
large  intestine  between  the  cecum 
and  the  rectum,  shaped  like  the  let- 
ter S. 

Singers'  nodes.  Enlargement  of 
the  edges  of  the  vocal  cords. 

Sinus.  A  recess,  cavity,  or  hollow 
space. 

Skeletal  muscle.  A  muscle  at- 
tached to  or  moving  some  part  of  the 
skeleton. 

Soft  palate.  Back  part  of  the  roof 
of  the  mouth. 

Speculum.  An  instrument  for 
openmg   to  view  a  passage  or  cavity. 

Sphenoid  bone.  The  small  wedge- 
shaped  bone  at  the  base  of  the 
skull. 

Sputum.  Matter  spit  from  the 
mouth. 

Stapes.  Stirrup-shaped  bone  of 
the  middle  ear. 

Sternum.  The  breast-bone,  to 
which  the  ribs  are  attached  in  front. 

Stertorous.  Of  the  nature  of 
snoring. 

Stimulant.  A  remedy  that  excites 
functional  activity  in  a  part. 

Stool.     A  fecal  discharge. 

Strabismus.      Cross-eye ;  squint. 

Sublingual  gland.  One  of  the 
glands  which  secrete  saliva. 

Submaxillary  gland.  One  of  the 
glands  which  secrete  saliva. 

Suspensory  ligament.  The  liga- 
ment that  supports  the  crystalline 
lens  of  the  eyeball. 


GLOSSARY. 


439 


Syncope.     A  fainting  condition. 

Synechia.  An  adhesion,  as  of  llie 
iris  to  llie  cornea. 

Syphilis.  A  contagious  venereal 
disease. 


Tapetum  lucidiim.  Tiic  irides- 
cent eijitlieliuni  of  the  elioroid  of 
cats. 

Tapotement.  A  tapping  manip- 
ulation in  massage. 

Tarsal  cartilages.  Thin  cartilages 
of  the  eyelids. 

Temporal  bone.  Bone  at  each 
side  and  base  of  the  skull  containing 
the  hearing  apparatus. 

Tenotomy.  The  operation  of  cut- 
ting a  tendon. 

Terminal  plate.  The  terminal 
expansion   of  a  motor  nerve-branch. 

Thermotherapy.  Treatment  of 
disease  by  means  of  heat. 

Thoracic  duct.  A  duct  in  which 
terminate  the  lymphatics  of  the  lower 
limbs,  abdomen,  left  arm,  left  side 
of  the  head,  neck,  and  thorax. 

Thorax.     The  chest. 

Thyroid  cartilage.  The  sliield- 
shaped  cartilage  of  the  larynx. 

Tinnitus  aurium.  A  ringing  in 
the  ears. 

Tonsils.  Two  almond-shaped 
bodies,  one  on  each  side,  at  the  open- 
ing of  the  pharynx.  These  are  the 
faucial  tonsils.  There  is  also  a  third 
XoVisW,  p/iarynffeal,  which  see. 

Tourniquet.  Instrument  for  the 
compression  of  blood-vessels  to  pre- 
vent access  of  blood  to  a  limb. 

Toxic.     Pertaining    to   poisoning. 

Trachea.     The  windpipe. 

Trachoma.  A  contagious  form  of 
conjunctivitis  ;   "  granular  lids." 


True  skin.  The  skin  beneath  tlic 
outer  skill  ;    the  derma. 

Turbinated  bodies.  Tincc  small 
bones  [Inrhiniilcd  luiiics)  of  the  nose 
and  their  vascular  coverings. 

Tympanum.  The  middle  ear  or 
ear-drum. 

u 

Urea.  A  white  crystalHm;  sub- 
stance from  urine. 

Uremia.  Accumulation  of  poi- 
sonous matters  in  the  blood,  due 
to  faulty  elimination  of  diseased  kid- 
neys. It  may  cause  convulsions  or 
coma. 

Uric-acid  diathesis.  A  predis- 
position to  the  formation  of  an  excess 
of  uric  acid. 

Urticaria.     Hives ;  nettle-rash. 

V 

Valve.  A  fold  in  a  canal  which 
prevents  reflux  of  its  contents,  as  the 
valves  of  the  heart. 

Valvulsa  conniventes.  Trans- 
verse folds  in  the  mucous  membrane 
of  the  small  intestine. 

Varicose  veins.  Greatly  enlarged 
and  contorted  veins. 

Vascular.  Pertaining  to,  or  full 
of,  vessels. 

Vasomotion.  The  contraction  or 
dilation  of  a  blood-vessel. 

Vermiform  appendix.  A  blind 
pouch  in  the  upper  portion  of  the 
large  intestine. 

Vibrissas.  The  hairs  within  the 
nostrils. 

Villi.  Small  projections  from 
the  lining  membrane  of  the  intes- 
tine. 


440 


GLOSSARY. 


Visual  angle.  Angle  made  at  the 
eye  by  lines  joining  the  extremities 
of  objects  and  the  nodal  point. 

Vitiligo.  A  skin  disease  charac- 
terized by  white  patches. 

Vitreous  humor.  Transparent 
semifluid   mass    in    the    eyeball   be- 


tween the  crystalline  lens  and  the 
retina. 

Voluntary  muscle.  Any  muscle 
controlled  by  the  will. 

Vomer.  Bone  which  forms  the 
lower  and  back  part  of  the  partition 
of  the  nose. 


NDEX 


Abdominal  muscles,  338 
Accidents  and  emergencies,  411 
Accommodation,  207 

failure,  209 

tests,  224 
Acetylene,  250 
Acid  steam-bath,  406 
Acids,  poisoning  JDy,  420 
Adenoid  growths,  105 
Advancement     of    eye-muscles, 

217 
Air,  liquid,  365 

purity,  128 
Air-cells,  function,  122 
Alcohol,      effect     on      muscular 
vigor,  326 
on  the  nervous  system,  291 

restorative  properties,  326 
Alcoholic  beverages,  40 

effect  on  vision,  255 
Alcoholism,  acute,  428 
Alkalis,  poisoning  by,  426 
Ametropia,  204 
Anisometropia,  209 
Anti-D  trap,  370 
Antrum   of  Highmore,    disease, 

104 
Anus,  17 

Appendix  vermiformis,  16 
Appetite,  26 
Aqueous  humor,  193 
Arc  light,  248 
Arcus  senilis,  184 
Argand  burner,  248 


Artificial  eyes,  273 

respiration,  421 
Ashes,  disposal,  375 
Asphyxiation,  from  gas,  424 

from  smoke,  423 
Astigmatism,  205 
Athletic  sports,  334 
Atropin,  219 
Auerbach's  plexus,  14 
Auricle,  140 
Automatic  movements,  319 

"  Babies'  sore  eyes,"  228 

Bacilli  in  the  air,  129 

Bacteria  in  water,  366 

"  Bad  breath,"  107 

Baking-powder,  adulteration,  385 

Baldness,  82 

Bandage,  four-tailed,  415 

handkerchief,  415 

many-tailed,  415 
Bathing,  60 
Bath-pruritis,  69 
Bath-rooms,  372,  374 
Baths,  acid  steam,  406 

classification,  61 

cold,  61 

foot,  404 

hot,  64,  403 

hot-air,  406 

Russian,  69,  403 

sheet-,  406 

Turkish,  68,  403 

.vapor,  403,  404 

441 


442 


INDEX. 


Baths,  varieties,  403 

warm,  63 
Beard,  care,  91 
Bedbugs,  391 
Bed-clothing,  81 
Belladonna,  219,  428 
Bending  exercises,  345 
Bicycling,  306 
Bifocal  lenses,  265 
Bile,  15 

Biliousness,  49 
Binocular     vision,     advantages, 

169 
Bites,  413 
"  Black  eye,"  172 
"  Blear  eye,"  175 
Bleeding,  control  of,  411 
Blepharitis,  175 
Blindness,  tests,  227 
"  Blind-spot,"  193 
Blowers,  363 
Boating,  307 
Brain,  compression,  424 

concussion,  424 

hygiene,  275 
Bread,  35 
Breakfast,  34 
Breath,  foul,  107 
Breathing,  exercises,  342 

physiology,  121 
Bronchial  tubes,  anatomy,  121 
Bruises,  414 
Brunner's  glands,  14 
Brushing  the  hair,  83 
Building  site,  350 
Burns,  416 
Butter,  adulteration,  385 

Caffein,  restorative  properties, 

325 
Canoeing,  307 

Carbon-dioxid,  estimation,  358 
Carpets,  357 


Carriage,  influence  on  digestion, 

44 
Cataract,  195 

causes,  196 

treatment,  196 
Cecum,  16 
Ceilings,  height,  352 
Cellar,  353 
Cerumen,  142 

impacted,  144 
Cess-pool,  372 

Chemic  causes  of  disease,  390 
Chest,  anatomy,  119 
Childhood,  exercise  during,  333 

nervous  and  mental  hygiene, 
279 
Cholesteatoma  of  the  ear,  1 54 
Choroid,  190 
Chyme,  15 
Cilia,  174 
Ciliary  body,  189 

muscle,  208 
Cleaning  clothes,  380 

house,  378 
Closets,  water-,  373 
Clothes,  disinfection,  380 

on  fire,  417 
Clothing,  72 

absorption  of  moisture  by,  73 

for  cold  weather,  73 

color,  75 

heat-conducting  power,  73 

rubber,  76 

for  warm  weather,  75 
Climate  in  consumption,  134 
Climatology,  136 
"  Coating  of  the  tongue,"  107 
Cockroaches,  391 
Cocoa,  36 
Coffee,  36 

effect  on  the  nervous  system, 
292 
Cold  bath,  61 


INDEX. 


443 


Cold  creams,  71 
Cold-douche,  407 
"  Cold  in  the  head,"  loi 
Cold  pack,  407 
Color-blindness,  225 

causes,  225 

tests,  226 
Combs,  83 

Complexion,  care,  70 
Compression  of  the  brain,  424 
Concussion  of  the  brain,  424 
Condiments,  37 
Conflagrations,  household,  418 
Conjunctiva,  178 
Conjunctivitis,  178 
Constipation,  48 
Consumption,  129 

climatic  treatment,  134 

prevention,  129 
Contusions,  414 
Convulsions,  in  children,  424 

epileptic,  424 
Cooking,  35,  384 
Cooling  the  air,  364 
Cornea,  183 

opacity,  183 
Corsets,  80 

influence  on  digestion,  45 
"  Cross-eye,"  216 
Crystalline  lens,  194 
Cubic  space  in  dwellings,  352 
Curarization,  spontaneous,  301 
Curtains,  354 
"  Curve  of  health,"  293 
Cuts,  411 
Cycloplegics,  219 

Dandruff,  82 
Deafness,  causes,  J  57 

tests,  164 
"  Degenerates,"  276 
Derma,  54 
Desks  in  school-rooms,  236 


Diarrhea,  48 
Dietetics,  381 
Diet,  mixed,  382 

regulation,  32 

vegetarian,  384 
Digestion,    influence     of    dress, 

44 
intestinal,  15 
physiology,  9 
stomachal,  13 
Digestive  apparatus,  hygiene,  9 
system,   effect  of  exercise  on, 

329 
Dinner,  34 
Diplopia,  216 
Disease,  causes,  389 

prevention  of  infectious,  390 

transmission,  390 
Disinfectants,  domestic,  379 
Disinfection  of  clothes,  380 

in  infectious  diseases,  392 
Dislocations,  415 
Diversion,  necessity,  298 
Dog-bites,  413 
Domestic  hygiene,  349 
Doors,  354 
Double  vision,  216 
Douche,  cold-,  407 
Drains,  369 
Draperies,  354 
Dress,    influence    on    digestion, 

44 
Drinking  water,  39 
"  Drops,"  dangers,  219 

reasons  for  use,  219 
Drip-sheet,  406 
Drowning,  421 

Drum-membrane  of  the  ear,  149 
Drunkenness,  428 
Dryness  of  the  air,  364 
Dumb-bell  exercises,  341 
Duodenum,  13 
Dust,  city,  374 


444 


INDEX. 


Dust,  from  stoves,   heaters,  etc. 

364 
Dwellings,  construction  and  fur- 
nishing, 350 

Ear,  external,  139 

foreign  bodies,  145 

hygiene,  139 

internal,  162 

middle,  155 
Earache,  1 58 
Ear-drum,  149 

artificial,  151 

disease,  153 

injuries,  152 
Earrings,  140 
Ear-trumpets,  168 
Ear-wax,  142 

impacted,  144 
Eating  after  exercise,  43 
Electric  fans,  364 
Electricity,  248 

injuries,  421 
Elevation  for  dwellings,  350 
Embroidering,  255 
Emergencies,  41 1 
Emmetropia,  204. 
Engraving,  255 
Environment,  influence,  276 

in  cause  of  disease,  393 
Epidermis,  52 
Epiglottis,  1 10 
Epilation,  90 

Epileptic  convulsions,  424 
Epiphora,  177 
Epistaxis,  425 
Ergograph,  326 
Eustachian  tube,  156 
Exercise  during  adult  life,  333 

amount  necessary,  335 

during  childhood,  332 

in  disease,  337 

eating  after,  43 


Exercise,  effect,  323 

on  the  blood-vessels,  326 
on  the  digestive  system,  329 
on  the  heart,  327 
on  respiration,  328 
on  the  skin,  329 

environment  and  clothing,  337 

excessive,  336 

kind  most   advantageous,  331 

necessity  of  regulated,  304 

physical,  315 

waste-products,  326 

during  youth,  333 
Exercises,  gymnastic,  338 
Exposure,  southern,  350 
Eye,  hygiene,  169 
Eyeball,  anatomy,  169 

wounds,  201 
Eyebrows,  171 
Eye-cups,  182 
"  Eye-drops,"  219 
Eye-glasses,  265 
Eyelashes,  174 
Eyelids,  172 
Eye-lotions,  182 
Eye-muscles,  215 
Eyes,  foreign  bodies  in,  198 

injuries,   198 

overwork,  243 

relation     to     general     health, 
256 
Eyestrain,     effect    on    nutrition, 
28 

local  symptoms,  211 

mechanism,  210 

in  myopia,  214 

reflex  symptoms,  212 

Face-lotions,  71 
Face-powders,  72 
Fans,  electric,  364 
Far-sightedness,  204 
Fatigue  of  muscle,  323 


INDEX. 


445 


Fats,  37 

consumption    of,    in    exercise, 
322 

restorative  properties,  325 
I'ilters,  domestic,  368 

municipal,  368 
Filtration  of  water,  368 
Fires,  house,  418 
First  aid,  41 1 
Fish4iook  wounds,  412 
Fleas,  391 
Flies,  391 

Floor-coverings,  356 
Floor-exercise,  346 
Floors,  356 
Food,  381 

adulteration,  385 

analysis,  383 

cost,  38?. 

infection  from,  384 

inspection,  386 

nutritive  value,  382 
Food-substances,  transformation 

into  energy,  321 
Foot-baths,  404 
Formaldehyd-disinfection,  380 
Foundations,  building,  350 
Four-tailed  bandage,  415 
Fractures,  415 
Freezing,  420 
Frost-bite,  420 
Fruits,  36 

Fumes,  noxious,  376 
Furnace-fire,  364 
Furnace-heating,  362 

Gall-bladder,  15 
Garbage,  374 
Garters,  79 

Gas-asphyxiation,  424 
Gas,  sewer-,  372 
Gastric  juice,  li 
Glaucoma,  197 


Glucose,     consumption      of,     in 

exercise,  322 
(Glycogen,    consumption    of,     in 

exercise,  322 
Golf,  advantages,  305 
Granular  lids,  179 
Gray  hair,  90 
Gymnastics,  334,  338 

Hair,  anatomy,  58 

care,  82 

dyeing,  91 

removal,  90 

singeing,  89 

superfluous,  90 

wetting,  90 
Hair-brushes,  83 
Hair-cutting,  88 
Hair-dressing,  89 
Hair-dyes,  91 
Hair-pomades,  89 
"  Hair-restorers,"  89 
Hallways,  354 

Handkerchief  bandages,  41 5 
Hats,  86 

Head-accidents,  424 
Head-gear,  86 
Hearing,  physiology,  155 

tests,  164 
Heart,  effect  of  exercise  on,  327 
Heat-exhaustion,  420 
Heating,  361 

and  ventilation  combined,  362 

excessive,  363 
Height  of  dwellings,  352 
Hematemesis,  425 
Hemoptysis,  425 
Hemorrhage,  control  of,  411 

of  the  lungs,  425 
Heredity,  influence,  276,  393 
Heterophoria,  216 
Holmgren-test,  226 
Homatropin,  220 


446 


INDEX. 


Home-gymnastics,  338 

Hook-fronts  for  spectacles,  267 

Hot  bath,  6^ ,  403,  406 

Hot-pack,  407 

Hot  vapor  baths,  404 

Hot- water  heating,  361,  362 

House-cleaning,  378 

-construction,  350 

-drain,  370 

-quarantine,  394 
Humidity,  359 
Humors  of  the  eye,  193 
Hunting,  307 
Hutchinson's  teeth,  19 
Hyperopia,  204 

Ileum, 13 
Illuminating-gas,  247 

asphyxiation  from,  424 
Illumination,  artificial,  245 

indirect,  246 
Incandescent  light,  248 
Indirect  illumination,  246 
Infants'  eyes,  care,  228 
Infection,  from  food,  385 

susceptibility  to,  392 
Infectious  diseases,  391 
Insalivation,  9 
Insects,  infection  by,  390 
Insect-stings,  413 
Insomnia,  311 

causes,  311 

treatment,  312 
Inspection,  food,  386 

meat,  386 

milk,  387 
Intestinal  digestion,  15 
Intestine,  large,  16 

small,  13 
Iris,  184 
Iritis,  189 
Isolation   in  infectious   diseases, 

391.  392 


Isolation,  time  of,  395 
Ivy-poisoning,  414 

Jaw,  dislocation,  415 
Jellies,  adulteration,  385 
Jejunum,  13 

Kalsomined  walls,  355 
Kerosene,  247 
Kindergarten,  dangers,  229 
Kitchen,  354 
Kyphosis,  125 

Lacrimal  apparatus,  176 
Laryngopharynx,  108 
Laryngoscopy,   1 10 
Larynx,  anatomy,  108 

examination,  110 

functions,  1 1 1 
Laundering,  379 
Leading,  242 

Lenses,  spectacle,  259,  262 
Lieberkiihn's  glands,  14 
Lighting,  234 

artificial,  244 
Lightning,  injuries  from,  421 
Liquid  air,  365 
Liver,  15 
Luncheon,  34 
Lungs,  anatomy,  121 

consumption,  129 

hemorrhage,  425 

tuberculosis,  129 

Mackintoshes,  76 
Macula  lutea,  191 
Manicuring,  92 
Many-tailed  bandage,  415 
Mariotte's  blind  spot,  193 
Massage,  409 

method,  410 

movements,  409 

rules,  409 


INDEX. 


H7 


Massage,  value,  409 
Mastication,  9 
Meals,  regulation,  30 
Meat,  infection,  386 
Meibomian  glands,  173 
Meissner's  plexus,  14 
Menstruation,  influence,  281 
Microbes  in  the  air,  129 
Milk,  adulteration,  385 

infection,  385 

inspection,  387 
Mixed  diet,  382 
Monocles,  268 
Mosquitos,  391 

bites,  413 
Mouth-breathing,  17,99 
Mouth-wash,  25 
Movement,  muscular,  315 
Muscae  volitantes,  194 
Muscle-fatigue,  323 
Muscles,  classification,  315 

physiology,  316 
Muscular  contraction,  316 
Mydriatics,  219 

dangers,  220 
Myopia,  205 

Nails,  care,  92 
Nasal  douche,  160 

duct,  177 

passages,  98 

septum,  deformities,  98 
Nasopharynx,  anatomy,  104 
Near-sightedness,  205 
Needle-wounds,  412 
"  Nerve-deafness,"  163 
Nerves,  anatomy  and  physiology, 

275 
"Nervousness,"  282 
Nervous  prostration,  282 

system,  hygiene,  275 

tissue,  275 
Neurasthenia,  causation,  283 


Neurasthenia,  definition,  283 

general  remarks,  282 

pathology,  289 

prognosis,  290 

symptoms,  285 

treatment,  290 
"  Nevo,"  365 
Noises,  city,  376 
"  Noises  in  the  ear,"  165 
Nose,  anatomy,  94 

care,  100 

mucous  membrane,  97 

picking,  104 

polyps,  99 
Nose-bleed,  425 
Nuisances,  375 
Nutrition,  disturbances  of,  27 

Ocular  muscles,  215 

Odors,  foul,  375 

Oil  of  vitrol,  427 

Oils,  37 

Old-age  sight,  209 

Olive  oil,  adulteration,  385 

Ophthalmia  neonatorum,  228 

Ophthalmoscopy,  187 

Opium-poisoning,  427 

Optic  nerve,  192 

Optician,  province,  257 

Organic  matter  in  the  air,  359 

Oropharynx,  anatomy,  106 

Overwork,  293 

mental,  294 

physical,  300 
Oxalic  acid,  427 
Oysters,  infection  from,  386 

Pack,  cold,  307 

hot-,  407 

partial,  40S 
Painted  walls,  355 
Pancreas,  1 5 
Pantoscopic  spectacles,  267 


448 


INDEX. 


Paper  for  books,  243 
Perspiratory  glands,  54 
Peyer's  glands,  i  5 
Pharyngeal  tonsil,  98 
Photophobia,  268 
Phthisis,   129 

climatic  treatment,  134 

prevention,  129 
Physical  exercise,  315 

training,  329 

and  mental  training,  329 
"  Pince-nez,"  265 
Pinguecula,  182 
Pleura,  123 
Plumbing,  369 
Poisoning,  425 
Poisons,  table,  429 
Polyps,  nasal,  99 
Pomades,  89 

Prejudice  against  spectacles,  269 
Presbyopia,  209 

Preserved  fruits,  adulteration, 385 
Printing,  241 

Prismatic  devices  for  lighting,  2  50 
Prussic  acid,  428 
Pterygium,  282 
Ptyalin,  9 
Puberty      and       its       attendant 

dangers,  280 
Pulse,  401 

Punctured  wounds,  412 
Pupil,  186 

Purifying  agents,  378 
Purification  of  water,  367 
Pyorrhea  alveolaris,  23 

Quarantine,  house-,  394 

Radiation  of  heat,  362 
Rat-poison,  429 
Rats,  391 

Reading,    hygienic    precautions 
in,  252 


Recreation,  need  of  mental,  298 

Rectum,  17 

Reflex  movements,  320 

Refrigerator,  354 

Relaxing  exercises,  347 

Respiration,  403 

effect  of  exercise  on,  328 

physiology,  1 21 
Respiratory  gymnastics,  127 
Rest,  need  of,  298 
Retina,  190 
Roof,  house-,  352 
Rooms,  size,  352 
Rose-test,  227 
Rugs,  356 
Russian  bath,  69,  403 

Salivary  glands,  9 
Salts,  39 
Scalds,  416 
Scalp,  care,  82 

massage,  87 
School,  time  of  entrance,  230 
School-books,  241 
School-buildings,  234 
School-children,     ametropia    in, 
232 

medical  examination  of,  241 
School-children's   eyes,    care   at 

home,  231 
School-hygiene.  233 
School-life,  dangers,  231 
School-rooms,  235 
Sclera,  184 
Scoliosis,  125 
Scotomas,  191 
Sea-bathing,  66 
Seats  in  school-rooms,  236 
Sebaceous  glands,  57 
Sewer-gas,  372 
Sewers,  369 
Sewing,  255 
"  Second-sight,"  197 


INDEX. 


449 


"  Second-wind,"  loo 

Septum,  nasal,  98 

Sexual  instinct,  influence,  281 

Shampooinj,^  84 

Shaving,  92 

Sheet-bath,  406 

Shoes,  76 

"  Shoulder-braces,"  127 

Shower-bath,  63 

Shrug-movemenls,  344 

Sick-room,  hygiene,  393 

Sigmoid  flexure,  17 

Singeing  the  hair,  89 

Singing,  113 

improper  methods,  115 
Sinks,  354 
Site,  building,  350 
Skin,  anatomy,  52 

and  its   appendages,  hygiene, 
52 

effect  of  exercise  on,  329 
Slates,  240 
Sleep,  308 

physiologic  considerations,  308 
Sleeplessness,  311 
Small-pox,   precautions   against, 

399 
Smoke-asphyxia,  423 
Smoke-nuisance,  375 
Smoking,  effect  on  vision,  255 
Snake-bites,  413 
Soap,  65,  70 

medicated,  66 
Socks,  79 

Soil  for  building  site,  350 
Soot-nuisance,  377 
Spectacles,  256 

advantages,  259 

bifocal,  265 

care,  263 

construction,  260 

fitting,  260 

initial  discomfort,  271 
29 


Spectacles,  invendon,  256 

necessity  of  changing.  273 

pantoscopic,  267 

position,  262 

prejudice  against,  269 

tinted,  268 

trifocal,  267 
Spine,  curvature,   125 
Splinters,  413 
Sponge-bath,  62 
Spontaneous  movement,  315 
Sports  and  gymnastics,  334 
"  Spots  before  the  eyes,"  194 
Sprains,  414 
Squint,  216 
Stairways,  353,  354 
Steam-bath,  acid,  406 
Steam-heating,  361,  362 
Steam,  inhalation,  418 
Steps,  354 
Stimulants,  41 
Stings,  413 
Stockings,  79 
Stomach,  absorption  from,  13 

anatomy,  1 1 

hemorrhage,  425 
Stomach-pumps,  426 
Stoves,  362 
Strabismus,  216 
Stretching  exercises,  341 
Strychnin-poisoning,  429 
Study,  regulation,  240 
Sugar,  37 

restorative  properties,  325 
Sulphuric  acid,  poisoning  by,  427 
Sunstroke,  420 
Superfluous  hairs,  90 
Susceptibility  to  infection,  392 
"Swedish  movements,"  335 
Sweeping,  379 

Tank,  flushing,  373 
Tea,  36 


450 


INDEX. 


Tea,  effect  on  the  nervous  sys- 
tem, 292 
Tear-apparatus,  176 
"  Tearing,"  177 
Tears,  overflow,  177 
Teeth,  decay,  20 

deformities,  17 

preservation,  23 
Temperature,  regulation,  55 

taking,  402 
Tennis,  306 
Tenon's  capsule,  170 
Tenotomy  of  eye-muscles,  217 
Test-types,  221 
Thermometer,  clinical,  402 
Thomson-stick,  226 
Thorax,  119 

deformities,  125 

muscles,  120 

phthisical,  127 
"  Thumb-sucking,"    18 
Tinnitus  aurium,  163 
Tinted  glasses,  268 
Tobacco,  effect  on   the  nervous 
system,  292 

effect  on  vision,  255 
Toilet-creams,  71 
Toilet-lotions,  71 
Toilet-room,  372 
Tongue,  "  coating,"  107 
Tonsils,  disease,  107 
Tooth-brushes,  23 
Tooth-powder,  24 
Tourniquet,  412 
Trachoma,  179 
Training,  physical,  329 
Traps  in  plumbing,  370 
Trifocal  spectacles,  267 
Tubercle  bacillus,  129 
Tuberculosis,  climatic  treatment, 

134 
prevention,  129 
Turbinated  bodies,  96 


Turkish  bath,  67,  403 
Twisting  exercises,  343 
Tympanic  cavity,  155,  158 

membrane,  149 
Type,  241 

Typhoid       fever,       precautions 
against,  398 

Vapor  bath,  69,  403,  404  . 
Varicose  veins,  80 
Vegetables,  infection  from,  386 
Vegetarian  diet,  384 
Veils,  effect  on  vision,  255 
Ventilation,  357 

artificial,  360 

natural,  361 
Ventilation    aud    heating,  com- 
bined system,  362 
Vermiform  appendiz,  16 
Vermin,  infection  by,  390 
Vision,  testing  acuity,  221 
Visual  tests,  221 
Vitreous  humor,  194 
Vocal  and  respiratory  apparatus, 

hygiene,  94 
Vocal  cords,  109 
Voice,  care,  113 

cultivation,  115 

excessive  use,  117 

"  throaty,"  1 16 
Voice-deterioration,  causes,    114 
Voice-sounds,  production,  112 

Wall-coverings,  354 
Wall-papers,  355 
Walls,  354 

building,  351 
Washing,  379 
Washing  soda,  379 
Waste-paper,  371 
Waste  -  substances,    production, 

during  exercise,  326 
Water,  39 


INDEX. 


451 


Water-closets,  373 
Water-purification,  367 

-supply,  366 
Water-waste  preventers,  374 
"What  to  do  in  case  of  fire, "418 
White-washinjjf,  •^gg 
"  Wild-hairs,"  175 


"Windmill  movements,"  345 

Window-ventilation,  360 

Windows,  354 

Windows  of  a  school-room,  234 

Worry,  297 

Wounds,  41 1 

Writing,  243 


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of  the  best  of  all  the  question  compends  and  will  no  doubt 
continue  to  enjoy  its  deserved  success." 

Essentials  of  Anatomy.  Charles  B.  G.  deNancrede,  M.  D.,  Pro- 
fessor of  Surgery  and  Clinical  Surgery  in  the  University  of  Michi- 
gan, Ann  Arbor.     i2mo,  400  pages,  180  illustrations.     Cloth,  $1.00  net. 


Fowler's  Operating  Room  just  issued 

Dr.  Fowler's  work  contains  all  information  of  a  surgical  nature 
that  a  nurse  must  know  in  order  to  attain  the  highest  efl&ciency. 
Cajiadiaji  Journal  of  Medicine  aiid  Siirge>y  says:  "We  find 
compactly  and  clearly  stated  just  those  thousand  and  one  things 
which  are  scattered  in  journals,  and  which  when  required  are 
so  hard  to  locate.  No  proceeding  is  advised  which  has  not 
been  amply  tested." 

The  Operating  Room  arid  the  Patient.  By  Russell  S.  FOWLER, 
M.  D.,  Surgeon  to  the  German  Hospital,  Brooklyn,  New  York.  Octavo 
volume   of   172   pages,   with  original    illustrations.       Cloth,  $2.00  net. 


Martin's  Minor  Surgery         new  (2d)  edition 

Nurses  will  find  this  book  of  much  value.  Full  directions  for 
applying  the  many  kinds  of  bandages  are  given  and  clearly  illus- 
trated; and  all  the  technic  of  minor  surgery  that  a  nurse  must 
know  is  plainly  presented.  The  New  York  Medical  Record 
says:  "  This  is  one  of  the  most  practical  books  that  one  can 
desire.     The  illustrations  are  neat  and  clear. ' ' 

Essentials  of  Minor  Surgery,  Bandaging  and  Venereal  Diseases.  By 
Edward  Martin,  M.  D.,  Professor  of  Clinical  Surgery,  Univer- 
sity of  Pennsylvania.     i2mo,  166  pages,  illustrated.     Cloth,  $1,00  net. 

Beck's  Reference  Handbook        just  issued 

This  little  book  contains  all  the  information  that  a  nurse  re- 
quires to  carry  out  any  directions  given  by  the  physician. 
The  Montreal  Medical  Journal  sa3^s  it  is  "  cleverly  systematized 
and  .shows  close  observation  of  the  sickroom  and  hospital 
regime.    The  book  can  be  recommended." 

A  Reference  Handbook  for  Nurses.  By  Amanda  K.  Beck,  Graduate 
of  the  Illinois  Training  School  for  Nurses,  Chicago,  111.  32mo 
volume   of    177   pages.  Bound    in   flexible    morocco,  $1.25  net. 


DeLee's  Obstetrics  for   Nurses 

JUST    ISSUED— NEW   (2dj    EDITION 

Dr.  Delyce  treats  obstetrics  from  the  nurse's  i)oint  of  view. 
The  book  really  considers  two  subject.s — obstetrics  for  nurses 
and  the  actual  obstetric  nursing.  Trai)icd  Niirse  aiid  Hos- 
pital Review  says  the  ' '  book  abounds  with  practical  sugges- 
tions, and  they  are  given  with  such  clearness  that  they  can- 
not fail  to  leave  their  impress  upon  the  mind  of  the  reader. ' ' 
The  practical  illustrations  are  nearly  all  original,  having  been 
made  specially  for  this  work. 

Obstetrics  for  Nurses.  By  Joseph  B.  DeLee,  M.  D..  Professor  of 
Obstetrics  at  the  Northwestern  University  Medical  School,  Chi- 
cago.    i2mo  volume  of  460  pages,  fully  illustrated.     Cloth,  $2.50  net. 

Davis'  Obstetric  &  Gynecologic  Nursing 

RECENTLY    ISSUED— NEW    (2d)    EDITION 

Obstetric  nursing  demands  some  knowledge  of  natural  preg- 
nancy and  of  the  signs  of  accidents  and  diseases  which  ma}' 
occur  during  pregnane}^  and  labor.  The  Trained  Nzase  and 
Hospital  Rcviczv  says  :  "This  is  one  of  the  most  practical  and 
useful  books  ever  presented  to  the  nursing  profession."  Gyn- 
ecologic nursing  is  really  a  branch  of  surgical  nursing,  and  as 
such  requires  special  instruction  and  training. 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Dan'IS,  M.  D., 
Professor  of  Obstetrics  in  the  Jefferson  Medical  College,  Philadel- 
phia.    i2mo    volume   of    402  pages,    illustrated.     Buckram,  $1.75  net. 

Paul's  Fever  Nursing  just  issued 

Dr.  Paul  has  laid  great  stress  upon  the  care  and  management 
of  each  disease,  as  this  relates  directly  to  the  duties  of  the 
nurse.  The  London  Lancet  thinks  "  the  book  is  an  excellent 
one  and  will  be  of  value  to  those  for  whom  it  is  intended. 
The  text  is  clear  and  full,   and  the  illustrations  are  good." 

Nursing  in  the  Acute  Infectious  Fevers.  By  GEORGE  P.  Paul. 
M.  D.,  Assistant  Visiting  Physician  and  Adjunct  Radiographer  to 
the  Samaritan  Hospital,  Troy,    izmo  of  200  pages.     Cloth,  $1.00  net. 


Friedenwald  and  Ruhrah's  Dietetics 
lOr    IN  urses  just  issued 

This  work  has  been  prepared  to  raeet  the  needs  of  the  nurse, 
both  in  the  training  school  and  after  graduation.  It  aims  to 
give  the  essentials  of  dietetics,  considering  briefly  the  physi- 
ology of  digestion  and  the  various  classes  of  foods.  Americaii 
Joicrnal  of  Nursing  says  it  "is  exactly  the  book  for  which 
nurses  and  others  have  long  and  vainly  sought.  A  simple 
manual  of  dietetics,  which  does  not  turn  into  a  cook-book  at 
the  end  of  the  first  or  second  chapter. ' ' 

Dietetics  for  Nurses.  By  Julius  Friedenwald,  M.  D.,  Clinical  Pro- 
fessor of  Diseases  of  the  Stomach,  and  John  Ruhrah,  M.  D.,  Clinical 
Professor  of  Diseases  of  Children,  College  of  Physicians  and  Sur- 
geons,   Baltimore.     i2mo   volume   of    365    pages.        Cloth,  $1.50  net. 

American  Pocket  Dictionary    new  (sVhfEDmoS 

This  is  the  ideal  pocket  lexicon.  It  contains  a  complete  vo- 
cabulary, defining  all  the  terms  of  modern  medicine.  The 
Trahied  Nurse  and  Hospital  Review  says  :  ' '  We  have  had 
many  occasions  to  refer  to  this  dictionary,  and  in  every  in- 
stance we  have  found  the  desired  information."  The  work 
also  contains  a  wealth  of  anatomic  tables  of  value  to  nurses. 

Dorland's  Pocket  Medical  Dictionary.  Edited  by  W.  A.  NEWMAN 
DORLAND,  M.  D.,  of  the  University  of  Pennsylvania.  riexible 
leather,  with  gold  edges,  $1.00  net;  with  patent  thumb  index,  $1.25  net. 

Grafstrom's    Mechano-therapy     (2d)  edu^n 

The  Boston  Medical  and  Surgical  Joicrnal  says  :  "It  states  in 
concise  language  the  various  methods  which  by  long  experience 
have  been  found  useful  in  treament  by  mechanical  means." 

Mechano-Therapy  (Massage  and  Medical  Gymnastics).  By  AXEL  V. 
Grafstrom,  B.  Sc,  M.  D.,  Attending  Physician,  Gustavus  Adolphus 
Orphanage,    Jamestown,  N.   Y.      i2mo,  200  pages.      Cloth,  $1.25  net. 

Friedenwald  &  Ruhrah  on  Diet   '^S^S^S^ 

Diet  in  Health  and  Disease.  By  Juivius  Friedenwald, 
M.  D.,  Clinical  Professor  of  Diseases  of  the  Stomach,  and 
John  Ruhrah,  M.  D.,  Clinical  Professor  of  Diseases 
of  Children,  College  of  Phj'sicians  and  Surgeons,  Balti- 
more.    Octavo  volume  of  728  pages.     Cloth,  $4.00  net. 


^tf^Vf>nQ'       PrJlPfiP^  RECENTLY  ISSUED 

Oieveila        rldCllLC  new  (7th)  edition 

During  his  absence  the  physician  depends  entirely  upon  the 
knowledge  and  watchfulness  of  the  nurse  to  report  to  him 
any  changes  that  may  have  occurred  in  the  patient's  condi- 
tion. Of  this  work  the  Buffalo  Medical  Journal  Sdiys  \  "Its 
arrangement  is  excellent,  being  such  as  to  facilitate  ready  ref- 
erence to  its  multifarious  subjects."  Dr.  vStevens  has  brought 
within  a  comparatively  small  compass  a  complete  outline  of 
the  practice  of  medicine. 

Practice  of  Medicine.  By  A.  A.  Stevens,  M.  D.,  Professor  of  Materia 
Medica,  Therapeutics,  and  Clinical  Medicine,  Woman's  Medical 
College.     i2mo  volume  of  556  pages.  Flexible   leather,  $2.50   net. 

Williams'    Practice  jushssued 

Throughout  this  book  special  stress  has  been  laid  on  dijEferen- 
tial  diagnosis,  symptomatolog}^  and  treatment.  The  New 
York  Medical  Nezus  says  "  the  symptoms  are  particularly  well 
abstracted,  and  give  the  book  real  value." 

Essentials  of  the  Practice  of  Medicine.  By  William  R.  Williams 
M.  D.,  formerly  Instructor  in  Medicine  and  Lecturer  in  Hygiene,  Cor- 
nell University.     i2mo,  461  pages.    Double  number.     Cloth,  $1.75  net. 

Morris'  Materia  Medica  new  (7th  edition 

'^\\e.  Trained  Nicrse  and  Hospital  Revieiv  says:  "The  work  is 
thoroughly  up  to  date,  well  arranged,  compact,  and  yoX.  con- 
tains a  very  large  amount  of  matter." 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription  Writing. 
By  Henry  Morris,  M.  D.  Revisad  by  W.  A.  Bastedo,  M.  D., 
Instructor  in  Materia  Medica  and  Pharmacology  at  the  Colum- 
bia University,  New  York.      i2mo  of  300  pages.       Cloth;  $1.00  net, 

Griffith's  Care  of  the  Baby    new  od)  edition 

The  New  York  Medical  Journal  saj's:  "We  are  confident  if 
this  little  work  could  find  its  way  into  the  hands  of  everj- 
trained  nurse,  infant  mortality  would  be  lessened  b}-  at  least 
fifty  per  cent. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  GRIFFITH,  M.  D..  Clinical 
Professor  of  Diseases  of  Children,  University  of  Pennsylvania. 
i2mo  of  436  pages,   illustrated,    including  5  plates.      Cloth,  $1.50  net 


Dorland's   Illustrated  Dictionary 

JUST   ISSUED— NEW    (4th)    EDITION— 2000  NEW   TERMS 

This  edition  contains  over  200  new  terms.  Dr.  Howard  A. 
Kelly  says:  "  Dr.  Dorland's  Dictionary  is  admirable.  It  is  so 
well  gotten  up  and  of  such  convenient  size.  No  errors  have 
been  found  in  my  use  of  it." 

The  American  Illustrated  Medical  Dictionary.  A  Dictionary  of  the 
terms  used  in  Medicine,  Surgery,  Dentistry,  Pharmacy,  Chemistry, 
and  l^indred  branches;  with  loo  new  and  elaborate  tables.  By  W. 
A.  N.  DORLAND,  M.  D.  Large  octavo  of  836  pages,  293  illustrations, 
iiq    in    colors.     Flexible    leather,  $4.50  net:   thumb   index,  $5.00   net. 

Bergey's    Hygiene  new  (2d)  edition 

The  American  Journal  of  the  Medical  Sciences  says  this  work 
"presents  in  compact  form  a  very  clear  exposition  of  the 
general  principles  of  hygiene,"  and  "  especially  to  be  com- 
mended is  the  chapter  on  vital  causes  of  disease." 

The  Principles  of  Hygiene.  By  D.  H.  Bergey,  A.  M.,  M.  D.,  Assis- 
tant Professor  of  Bacteriology  in  the  University  of  Pennsylvania. 
Octavo    volume    of    536  pages,  fully  illustrated.       Cloth,    $3.00    net. 

Abbott's  Transmissible  Diseases  (2d)  EDmoN 

In  speaking  of  Dr.  Abbott' s  book  the  Johns  Hopkins  Hospital 
Bnlletin  says  :  ' '  The  book  is  w^ell  calculated  to  meet  a  want 
which  has  long  been  felt  by  physicians  and  nurses." 

The  Hygiene  of  Transmissible  Diseases.  Their  Causation,  Modes  of 
Dissemination,  and  Methods  of  Prevention.  By  A.  C.  Abbott,  M.D., 
Professor  of  Hvgiene  and  Bacteriology,  University  of  Pennsylvania. 
Octavo    volume    of    311   pages,  fully   illustrated.       Cloth,  $2.50    net. 

Pyle's  Personal  Hygiene  new  (2d)  edition 

A  Manual  of  Personal  Hygiene.  Proper  Living  upon  a 
Physiologic  Basis.  Edited  by  Wai^TER  L.  Pyi,E,  A.  M., 
M.  D.,  Assistant  Surgeon  to  Wills'  Eye  Hospital,  Phila- 
delphia.     Octavo,  350  pages.      Illustrated.      |1.50   net. 

Barton  and  Wells'  Thesaurus    unique  work 

A  Thesaurus  of  Medical  Words  and  Phrases.  By 
Wilfred  M.  Barton,  M.  D.,  and  Walter  A.  Wells, 
M.  D.,  of  Georgetown  University,  Washington,  D.  C. 
12mo  of  534  pages.  Flexible  leather  $2.50  net;  with 
thumb  index ,  $3 .  00  net . 


'^'O 


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